GW1-2022-03785_Well Construction - GW1_20220404

-.--I 1 v 11Iv%,11 V lv 1 J I For Internal Use Only: I
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1.Well Contractor Information: I
•14:.WA.TER ZONES
Well Contractor Name FROM TO I DESCRD'TiON
qS�a-� It
4L ft
ft ft.
NC Well Contractor Certification Number '15:O=RG%ASING,(fdi multi-"disea w'e]Ls OR
Morgan Well&Pump, Inc. ) Im'?ER(iSa'IIeaBle) t
FROM TO' DMAIETER THICKNESS MATERIAL
+1 ft. O ft. 6 1181 Ii !in. sdi'21
Company Name pvc
6�C�j� 16�IaTER CASING OR-TOBIlYG.' e6tliermal'cl6'sed-lod' '•;', :•:%
2.Well Construction Permit#: s FROM To DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits'(be UIC,ColaIN State,Ph lance,etc.)- ft. ft I in.
3.Well Use(check well use): ft ft• in.
i
UAAgiicultural
Supply Well: 11-SCREEN', -
FROM TO DIAMETER' SLOT SIZE JTCCKNESS MATERIAL.
0Municipal/Public ft ft hiJ
ermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
rial/Commercial E3Residential Water Supply(shared) B:GROIIT::. '":•r--': -
I
Lion FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: o ft 20 - ft bentdnite•,• poured
oring Recovery ft ft
n Well:
ft ft
r Recharge Groundwater Remediation r
:.7.9:SAND/GRAVEL'PACK rf ii'lica611: •"::._'=::'._` ..• - - ..
r Storage and Recovery Salinity Barrier FROM • TO MATERIAL EMPLACEMENT`A=.OD
r Test 13stormwater Drainage ft ftmental Technology Subsidence Control ft ft.
rmal(Closed Loop) Tracerrmal(Heating/Cooling Return) J Other(explain under#21 emarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta)
4.Date Well(s)Completed: 1491- Well ID# O. ft p, ft �� r
Sa eppL/ovation: b tt95 ft SOI�
`�\rU./ 3m-, Pokr ft r ft rC-4
a
Facility'/OwnerName fi Facility lD#(if applicable) ft ft
7{� l�Q/►S GC� t n� G7���� ft ft.
PItysical6ddress,City,and Zip /► /i �e ft ff.
:21il2FMARTIC'.:-T i..::.,. '`:f:.. r+J:.-.,.:• ;,c�..1
V/
County Parcel Identification No.(PIN) APR —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one lat/long is sufficient) g�ye e
n�- q p. 22.Certification: :7a� al
�-
6.Is(are)the wells)WPPermanent or ©'(Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceiliify that the'wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ;Yes or E&I-0 with ISA MCA 02C.0100 or ISA MCA 02C.0200 Well Construction Standards and that a
If this is a repair fill out(mown well construction hiformation and explain the nature of the copy ofthis record has been provided to the,,vell 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,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface:_ L!ti J (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(a 200'mui 2Q100) construction to the following
10.Static water level below top of casing:
•Ifwater level is above casing,use"+" � (ft.) Division Of Water Resources,Information PYOCeS51Irg Unit,
1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells': 'In addition 11 to sending the form to the address in 24a
12.Well construction method: Y L� above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,duectpuslr etc.)
construction to the following: I
Division of Water Resources,Underground Injection Control Program,
[13b.Dissinfection
OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Yield air pressure �`
(gpm) - Method of test: P 24c.For Water Sunnly&Injection Wells: In.addition to sending the form to
-_ /I the address(es) 'above, also submit one copy of this form within 30 days of
type: !'s,^ CA e- Amount: 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