GW1-2022-03790_Well Construction - GW1_20220404

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r I1.Well Contractor Information:
�S C i 14:.WATESt ZONES
Well Contractor Name FROM TO DESCRIPTION
ft .� ft � .
i
ft. ft
NC Well Contractor Certification Number
�• '15:OUXER,t%ASING;(fo'r multiseised wells)QIt L•INEIt(if a"livable)'-;':�::',:.::'•.`.
Morgan Well&Pump, Inc. _ FROM TO' DIAMETER THICKNESS MATERIAL
Company Name +1 ft /i ft 6 1181 in. sdr21 pvc
16.INNER CASING OR•TQSIIYG.' eothermal closed loo`
2.Well Construction Permit#: 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(Le.MC,Courriv,State,Variance,etc.)- ft ft. ! in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.'sCREEN'.- �; •. _•:::.:,:::;:. :'•' ::,.: •:;,.;,.: ::.. ' .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculturalr-ilMunicipal/Public ft ft in:
!Geothermal(Heating/Cooliug Supply) &Residential Water Supply(single) ft ft in.
I IndustriaUCommercial E3Residential Water Supply(shared) GROUT-.' • r'`-''•:_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite. poured J
s Monitoring Recovery ft. ft.
Injection Well:
__!Aquifer Recharge []!Groundwater Remediation ft ft ;
:.79:SAND/GRAVELTACK if a"liciMb
Aquifer Storage and Recovery !Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
LExperimental
er Test r3Stormwater Drainage ft ft
Technology Subsidence Control ft ft
ermal(ClosedLoop) Tracer :20.'DRUL7-NG.L'OG•(itticli=additiouals'Iieetsffiiecessa :.,)FROM TO DESCRIPTION(color,hardness,soillrock type,grnin size,etc.)
ermal(Heating/Cooling Return) Other(explain under#f21 Remarks)
ft A ft
4.Date Well(s)Completed: Well ID# / ft it. &6"., '`o L�
5a.Well Location: ft ft 7 .,i S e./'}�
ft ��p ft �J i yrC�n;'•Q,
Facility/Owner Name Facility M#(ifappyllicable) 1 'a. ft- � ft- I i7 L q��
ai)AS �lJ/�py��, Lr✓1 �r /'�e5s � ft ft \1
Physical Address,City,and Zip ft. ft ? R L
SZ7/.rr7.Sr�yo d aQ '21:I�MARKS' :j' fi'
M
County Parcel Identification No.(PIN)
AVR
Sb:Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
( eUeld,gne l((at/long is sufficient) 22.Cer
G1 /� tification:
n "j' 4•N gD; Ala l W To .G j,1f11
gpe"
6.Is(are)the wellOAPermanent or OTemporary Sigrr�atitreofCertified Well Contractor Date
�,�{ By signing this form,I hereby cer•t�that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with ISA NCAC 02C.0100 or 15A NCAC 02C,0200 Well Consh•uction Standards and that a
Ifthis is a repair fill out known well constr•uctiah information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 r-emarks 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 land surface: (ft) 24a. For All Wells: Submit this fdim within 30 days of completion of well
For multiple wells list all depths 1fdier•ent(example-3(200'an d2@!�0D construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resource's,Information Processing Unit,
Ifwater level is above casino use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.]Borehole diameter: 6 (in.) 24b.For Injection 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: LALp
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
LFOR WATER SUPPLY SELLS ONLY: Division of Water Resources,Underground Injection Control Program,
t _ 1636 Mail Service Center,Raleigh,NC 27699-1 63 6
.Yield(gpm) Method of test: air pressure 24c.For Water Suuuly&Injection Wells: In addition to sending the form to
�ithe address(es) 'above, also submit one!copy of this form within 30 days of
.Disinfection type:_ ,f ,A Amount: completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016