GW1-2022-03775_Well Construction - GW1_20220404

WL+LLUL)-N6'1.'.KUC:'11QNRECORD (QW-1) For Internal Use Only. i)
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1.Well Contractor Information: r
�1�ff& V1�lJS�+ •14:.WA.TERZONES-C. r ?:i. ,•.r,: :i''•....;'.':'..._:.:;
Well Co t aeto Flame OM TO - DESCRiPT10N -
11 S _ ft ft 1
O ft ft
NC Well Contractor Certification Number ' t
� '15:OII�ER:QASINts,({o"r multi=rasedw'eIIs)OR I;II�R(if'a"livable}' ;�:;?:.::'•. J
Morgan Well&Pump, Inc. FROM TO: DIAMETER' _THICKNESS MATERIAL
Company Name +1 ft ft. 61/S1 I- Imo' sdt27 pvc
36�'��0 16"IlVNERCa1SIl�TG012•TQBIlIG "eotliermalclo'se3lod' :, _ 2.
2.Well Construction Permlt#: V FROM TO DIAIIM= THICIKNESS MATERUSL
List all applicable well constructionpermits'(i.e.WC;County,State,Patiance,etc.), ft. ft. :in.
3.Well Use(check well use): It. ft' I, in.
Water Supply Well: .. 17.'SCREEN::r:.. :t::. .'w< ='`•!::- :;:•'.::-•;..:�,:::.v-::i-= ::.. =:
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
Agricultural Mi MunicipaliTublic ft. ft in.l
i Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in i
I Industrial/Commercial E311esidential Water Supply(shared) -,.•.
:'In-i ation FROM TO MATE AL - EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: a ft 20 ft* bentanite.i poured
Monitoring 13Recovery ft ft.
Injection Well-
ft ft
_J Aquifer Recharge ' Groundwater Remediation :T9:SAND/GRAVEL'P9 CK ff a"livable "
Aquifer Storage and Recovery UISalinity Barrier FROM TO MATERLiL EMPLACEMENT METHOD
l Aquifer Test r3stormwater Drainage- ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer I:20.DRILLING.1-0, sWetsifneces's"
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain s ze etc)
V d ft ft
4.Date Well(s)Completed.- -a Well ID# ft Is ft
5/a. Location: �, e5)re V ��Q (� ft-
Well
/ -- p ft Q ft
r I�cw.��-ems
Facility/Owner Name Facility ID#(if applicable) V ft G ft
ft ft
Ph y'al Address,City,and Zip ft ft
i County Parcel Identification No.(PIN) J -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if w d,one lat/long is sufficient)
d 22.Certification:
-6 766 9 "N p0. W �� 3� ��� i�� ����.eY191'py 5 r'Ar{"9U. pi f r
6.Is(are)the well(s)oPermanent or J_'(Temporary Signature of Certified Well Contractor Date'
By signing this form,I hereby certify that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or nNo with 15.4 NCAC 02C.0100 or 15A NCAC 62C,0200 Well Construction Standards and that a
If this is a repair;fi1Z out known well construction Information and explain the nature of the copy ofthis record has been provided to the we11 owner.
repair under 421 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells i•
drilled: �l ,LI SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30,days of completion of well
For multiple wells list all depths if different(example-3 ,200'mtd 2@100D construction to the following
10.Static water level below top of casing: �I 6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above cdsing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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 form within 30 days of completion of well
12.Well construction method: r Y Lp construction to the following: 4
(Le,auger,rotary,cable,direct push,etc.) t
FOR WATER SUPPLY7j�ONLY- Division of Water Resources,Underground Injection Control Program,
1636Mail Service Center,Raleigh,NC27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suuuly&Infection Wells: In addition to sending the form to
/ the address(es) 'above, also submit one;copy of this form within 30 days of
13b.Disinfection type: r/-,,Ul"4 Amount: �'1 OL completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2 22 2016
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