GW1-2022-10736_Well Construction - GW1_20221208

W-ELbU0_NbT.KUG110NRECORD (GW-11 7orornalUseOnly.
1.Well Contractor Inf,rmation:
•14:.WATERZONES:'. •''
FROM TO DESCRIPTION r
Well Contras orName
ft ft i
ft ft.
NC Well Contractor Certification Number 15:OUPER:Ct}SING,(foI multi=tiger veils)O_RE (ifa"
Morgan Well &Pump, Inc. =" FROM TO' DIAMETER' TMCIfiTas MATERIAL
• +1 ft ft. 61lS/ I m' sd21 pvo
Company Name n t� ` <.._' ::;.
/u 16."AIR CAMNG OIt-TUBING'�eothe"r'maq,aoose&loa'
2.Well Construction Permit#: FROM TO DLIMETER TfficlnvEss •• MATERIAL
List all applicable well constructianpermits•(ie.UIC,County State,Yaumce,e� ft f, m.
3.Well Use(check well use): ft ft •
17._SCREEN',:•: : .I. :.x. :••..• :.;:. i;.�_ ..:r,. : , 71
Jatj
Supply Well: -. . w,. .._._.,.-•.•.•:.•. ..:•:,..
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Acultural DMunicipaVPublic ft ft in.
Ghermal(Iieating/Cooling Supply) (Residential Water Supply(single) ft ft in•
ndust.a]7Commercial _I Residential WaterSuPP1Y(shazed) ::YB;GROUT::.. :; :::'.; ':'::'.^:_`'':<.:-`-• '' :": ::•"::` "'
!Ins ation FROM TO MATERIAL EMPIACEMENTMETHOD&AMOUNT
Nan-Wafer Supply Well: 0 ft Zp ft bentonite• poured
s Monitoring Recovery ft. ft
Injection Well:
ft ft
_,Aquifer Recharge [J Groundwater Remediation I.
T9:SAND/GRAVEL'PA:=if a"iiciBle ••':_. '::: .• 1 c!: :
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EiViPLACEMENT METHOD
I Aquifer Test Q!Stormwater Drainage ft ft
f Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRn=NGSAG'(atticE-dditiouslsheedsEaeces's_7'^'^>`t=
r Geothermal(Heating/Cooling Return)) . Other(explain under 021 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain
��Jf o 0
4.Date Well(s)Completed: t/ __ C Well ID# ft ft
5a.Well Location: D •�l' 104�/L G
Spne ftoCb1-/eel &,1*f V S ft 0ft- Gn,l�b
Facility/O]wnerName (� ��� Facility ID#(ifapplicable) ft t f
ey" c ft ft.
Physical Address,City,and Zip
' ft ft a• a
n(p
F'
County Parcel Identification No.(PIN)
5b.Latitude and Iona tude in deg ees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CWtiouS5 .5eI to -N el, ZZ Z�7
6.Is(are)the well(s)Opermanent or r3Temporary Signa a of Certified Well Contractor Date
By sio uno this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is thi a repair to an existing well: ©Xes or Na wish 1SA NCAC 02C.0100 or 15A NCAC 02C..0200 Wdl Construction Standards and that a
Ijthis is a i epair,fill out]mown well construction iiiformadon and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
• 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUIvMER•ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welt]1st all depths ifdifferent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 MailService Center,Raleigh,NC 27699-1617
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11.BoreIroIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
f above,also submit one copy of this.foam within 30 days of completion of well
12.Well construction method: L6 construction to the following: i
(Le.auger,rotary,cable,duectpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELL&ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Suuuly&Infection'Wells: In addition to sending the form to
p / the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: (. Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2 22-2016
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