GW1-2022-03782_Well Construction - GW1_20220404

=.u�u�.v1�u 11t U l J_A"I 11'C�( "±W (U W_I) I For Internal Use Only: i
L Well ontractor Information':
•14:.SdATER ZONES
Well Contractor Name I FROM I TO DESCRIPTION
�.7�O� � ft t � ft t � •
NC Well Contractor Certification Number ft
F1S OUTER,eASING0&multi=ra we1 ses Ls)OR L (if a'ticable)'-;:::','.::'•.'.d
Morgan Well&Pump, Inc. FROM TO' I DIAMETER! I TMCM-,MSS MATERIAL
+1 1 ;in- sd21 pvc
��,��u�, 16"1NNER Ci1SING OR•TIIBIlS'G.''eotliermal'clo'sed-lob`:. "=';•' ;
2.Well Construction Permit#: ( FROM To DIAMETER THICIams I MATERIAL
Lisi all applicable well construction permits'(:.e.FAC,County,State,Variance,eta)- M ft
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.-SCREEN', -
I om I TO DrAmETERi I SLOT SIZE y7FIICKNESS l4fATERiAL.
Agricultural _i Municipal/Public ft ft in.
!Geothermal(Heating/CoOling Supply) Residential Water Supplysm le
- ( g ) ft ft
IndustriaUCommercial i Residential Water Su 1 shared
Supply( ) 18.GROUT-.'. .. . r�..c.+•..:.:�.:. :t:•::• ;. `•:;:. .a•-:_
I Itri ation FROM TO MATERIAL - EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. Zc ft bentonite• poured
Monitoring Recovery ft. ft.
Injection Well:
ft ft
_.I Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salmi Barrier :�:SAND/GRAVEL PACK rf a"lica6le ':.:;. =::;: :'•.',=
tY FROM TO MATERIAL EMPLACEMENT AIETHOD
Aquifer Test bstormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) OTracer �20, RILLING.L"OG'(itt6cl? dditiousl i ieets if iiecess""•:•;' iV.
Geothermal(Heating/Cboling Retum) [I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type grain size,eta)
ft � ft
4.Date Well(s)Completed'Vc� Well ID# 2U ft ftRfn_,�,
5% JI eII Lo`�tion: b ft 0 oft- (_ (� .
1� b00 U s � ft � ft �1
Facib�/�ner Name {� Facility ID/#�(if applicabl ft. ft
LGl(�CC�Of�r l�ld l,(�nlOd� ft. ft.
Pbysic;Address,City,a``ndZip ft ft "
YV✓J _ vJ��/ C.���� MARKS'
County Parcel Identification No.(PI1,4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AFR
(if ell field,one lat/long is sufficient)
��� N ('Y o , qq 22.Certification:'
PVC W �o56+-_
'.�v•,nv
6.Is(are)the well(s)0;Permanent or E (Temporary Signafiue of Certified Well Contractor Date
By suing this form,I herebv certify that the wells)way(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or [JNo —. with 15ANCAC O2C.0100 or]SA NCAC 02C,0200 Mell Construction Standards and that a
Ifil:is is a repair fill out known well construction hiformation and explain the natty a of the copy ofthis 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 NUMBER'of wells construction details.-You may also attach additional pages if necessary.
V drilled: . 1 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9—?o (ft 24a. For All Wells: Submit this form within 30 dayg of completion of well
For multiple wells list all depths if different(example-3 a 00'mid 2@1000) constmction to the following: '
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Mail Service Center,'Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: 1n addition to sending the fomr to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
Etype:'
UPPLE DVELLS ONLY: 1636 Mail Service Cent`r,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water Sunniv&Iniection We1.11s: In addition to sending the form to
r the address(es)`above, also submit orie(copy of this form within 30 days of
5 u O. Amount: lS completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016