GW1-2022-03778_Well Construction - GW1_20220404

I.Well Contractor Information:
t l
—� 14..WA.TM ZONES: P
Well Contractor Name FROM TO •DESCRIPTiOM I.
ft fL J
156
ft. ft
NC Well Contractor Certification Number
k 15:OU2ER,G�ASING',(fnc pLdti 6,.ca wells)ORLIlIETt
Morgan Well&Pump, Inc. : FROM TO' DIAMETER I THICFf`alFSS MATERTdS•
Company Name +1 ft ft. 61/8/ m'i jsdr21 pvc
. �'lJ! J I^ 16"INNER Ce1SIl�iG 012•TUBII�G. •eottier'rnal'cio'sed-Ion"?::.:"�'=' :;%�••'.,•:. .
2.Well Construction Permit#: 7 `� FROM TO. DTAhrtt:TFu THICKNESS MATERL41
Psi all applicable well construction permits'(r.e UIC,Co dy,State,Ymiance,etc)• ft. ft �+
3.Well Use(check well use)- ft ft
VAI;dcultural
upply Well: Y7.-SCREEN.­-.
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
rjMunicipal/Public ft ft in.
rmal(Heating/Cooling Supply) i�l'Residential Water Supply(single) ft ft
11duLStrial/COmmemial E3Residential Water Supply(shared) Y8:GROUT•::." _ --:r?•'•°•'•::
Irll ation FROM TO MATERIAL - EMPL.ICEMENTMETHOD&_1MOUNT
Non--Water Supply Well: p ft. 20 ft bentanite• poured
Monitoring 1311ccovery ft. ft
Injection Well:
ft ft
I'Gleothermal
Aquifer Recharge J GroundwaterRemediation
Aquifer Storage and Recovery Salim Bawer ; SAND/GRAvmPAcK if ie••lica6re ty FROM •TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test �Stomawater Drainage ft ftExperimental Technology oSubsidence Control ft fteothermal Closed Loo( p) 1ITracer , :20-T)MI INGM0G'(attachaddidi;iilsWe6Jfaecess"W.':y eating Conlin Return FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ete)
(Heating g ) J other(explain under#21 Remarks)
• r� /�q ^ d .ft J ft
4.Date Well(s)Completed: �1"/� 1�°t� Well ID# �,. RLk, ft.
5a Well
Location: b ft ft
S S�et a
S44/ NoAe,s ( -` ft LQ ft nwl�
Facility/Owner Name Facility My(ifapplicable) e1 ft• qgo ft
1530 'L ILV-/ {2h Je
ft ft
Physical Address,City,and Zip '
ft ft
VOW 6 r— l oG naaRuc° a1;. `:,•'
County Parcel IdentificationNo-(PIN) t
5b.Latitude and longitude in deb ees/minutes/seco4ds or decimal degrees: -
(ifwell field,one lat/iong is sufficient) 22.Certification: AR I� `Y '2V 69� .N gd, � W H a�
6.Is(are)the well(s) Permanent or OTemporary Siena of Certified Well Contractor
By signing this form,I hereby certify that the wells)waF Lbnsiructed in accordance
7.Is this a repair to an existing well: QYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Construction SYandmds and that a
If this is a repair J117 out known we71 construction idformation and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: ' I I :d(' SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: of completion of well 2 4a. For All Wells: Submit this form within 30 dayss
For multr'ple wells list all depths ifdierent(example-3 a 00'aJnd 2@100) (ft) construction to the following
10.Static water level below top of casing:•Ifwaterleve!is above casino use"+•' (ft
) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection WeIls: In addition to sending the form to the address in 24a
12.Well construction method: r o 0above, also submit-bne copy of this form wilfhin 30 days of completion of well
(i.e.auger,rotary,cable,directpush,etc.) J
construction to the following:
Division of Wafer Resources,Undergrpuud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) - Method of test air pressure 24c.For Water SuDDIv&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: 4AJ Od Amount: t��f completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of WaterResources { Revised 2-22 2016
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