GW1-2022-03800_Well Construction - GW1_20220404

rorInternal usetlnty:
f
I.Well C or Informati :
I .
14:.WATER ZONES-,'.
Well ConAle FROM TO DESCRIPTION
ft ft.
3 — ft ft
NC Well Contractor Certification Numbet
IS:OUM-RCASING.(fo'r&ulti-ra$ea wells)OR BINER(if a'
M rgan Well&Pump, Inc. FROM TO I DIAMETER I THICKNESS MATERIAL
+1 ft. ft. 61181 , in. sdr11 pvc
Company Name
♦ I 4��` 16`DTNER CASING OR•TUBIlNG''e6tliermal'a6'sed-lod`:
2.Well Construction Permit 4:_ 1.1 2 Wz I���y� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'Cl.e•EUC,County,state,po iance etc)- ft ft. in.
3.Well Use(check well use): ft it in.
UAgdcuitunal
upply Well: 11-SCREEN'..:- t _ '•� - .;r,.-
FROM TO DIAMETER, SLOT SIZE .T'HICKNESs MAT'ERTAL
i Municipal/Public ftft in•
rmal(Heating/CooIing Supply) Residential Water Supply(single) ft ftial/Commercial i Residential Water Supply(shared) Y8:GROUP r:=
Ini ation FROM TO MATERIAL EMPLACEMENT1v=0D&AMOUNT
Non--Water Supply Well: o ft- zo ft benionite• poured
t Monitaling Recovery ft. ft
Injectionion Well:
ft ft.
_ Aquifer Recharge EJ GroundwaterRemediation
::19.SALVD/GRAVEL'PACK if a 'licaSle
Aquifer Storage and Recovery Salinity Barrier FROM TO I EMPLACEMENT METHOD
Aquifer Test OIStormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OITracer ;20.DRIIdIOVG.L'OG'(attacli'additiorialsl�eets�ffieces's"'j':{ =;.
Geothermal eating Conlin Return W- t4640f,
DESCRIPTION(color,hardness,soiliroek type,grain s ze eta)
g )n -i_Other(explain under#/21 Remarks)41 Date Wells)Completed:31 (�/ Well ID#/ LO�I1 `Spa�WjeI/f/Location �}� �,�,jw./_ r'ocl 1 dm Ace. t, I/L ah&sr
Facility/Owner Nllame// Fac''ty I1(if applicable) ft ft
zQ7f W� Ao�_ ft ft.
Physical Address,City,and Zip /��7•//� //x_ ft ft
__jL. �Nr�` _ �r I�! (/�Z(3 `21:'R�'MA.RKC'- '<:•,- `i _i:�`t::v r ..,•..•'`
ra.
t%ouut3' Parcel Identification No.(PIN) <- g!'•• •_S':L�, 1 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) J22. ffification: �}P - 4•�0�,v,A6.Is(are)the well(s)JIPermanent or EI Temporary ertified Well Contractor ; �jt�ii�'''� 'l4'his form,I hereby cer tiV—flrXt he we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 11 Yes or No with 15.4 NCAC 02C.0100 or ISA NCAC 02C•.0200 Mell Construction Standards and that a
IJ this is a repair fill out(mown well construction idformation and erplain the nature ofthe copy ofthis record has been provided to the hell owner.
repair under#21 remarkv 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,plovide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NTJIvMFR of wells construction details. You may also attach additional pages if necessary.
drilled: • r
SUBMITTAL INSTRUCTIONS
9.Total well depth below T& nt
(ft) 24a. For All Wells: Submit this folm within 30 days of completion of well
For multiplewells list alldepthle-3��'and2@I00� construction to the following:
10.Static water level belo (ft) Division ofWater Resources,Information Processing Unit,
fwater level is above casing,u
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 I (in.) 24b.For Infection WeIIs: In addition,to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1AL construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
[13b.
R WATER SUPPLY 1�ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.Yield(gpm) `/'([ Method of test: air pressure 24c.For Water Suuuly&Iniection Wells: In addition to sending the form to
,/�I,� p, / the address(es) 'above, also submit wile copy of this form within 30 days of
Disinfection typ / � %L Amount: [ geyZ' completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
I