GW1-2022-05614_Well Construction - GW1_20220610

1.W ontr nf lion:
-14:.WATZR ZONES:'. -
Well Con Name FROM TO I DESCRIPTION
ft ft
pA ft ft
NC Well Contractor Certification Number
'15:OUT7_P1 g2ASING,(fo`r multwiisea wi us oR-=ER(ifa'liciwe)'1
Morgan Well & Pump, Inc. FROM TO' I DIAMETER I THICKNESS MATERIAL
Company Name +1 ft ft 6 1/8/ � in. sdr21 pvc
�n ^' 16.-lN ER CAMNG OB•TOBING.rpi6thelin2a closed loo
2.well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL' ^
List all applicable well constructionpermits'ri.e.UIC,Casty,State,Variance,etc). ft. ft in.
3.well Use(check well use): fr' ft' in.
Water Supply well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL.
1 Agricultural CIMunicipal/Public ft. ft
Geothermal(I-ieatiag/Cooling Supply) &Residential water Supply(single)
_ ft ft.
In 1c us/Commercial I Residential water Supply(shared)
.:18:GROUT: . ..
!Isi lion FROM TO MATERIAL EMPL_4CEMENT METHOD&AMOUNT
Non-water Supply Well: 0 ft 20 ft bentonite( poured
Monitoring Recovery ft. ft.
injection.well:
ft ft
_ Aquifer Recharge KI Groundwater Remediation
,.19:SSND/GRAVEL'PACK ff a'-licafiI'e ."'.r. =':;:':.:._ .:•, -,.',•'•:•':.'•.:'-:'';'•:.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft
i Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer :20.tiRILLING.I OG'attacli`additiorisl seetajf aecess ")'+' :•:'a
t Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPT ON(color,hardness,soil/rock e,grain size,ete)
�'�� �s�� ft ft I RA A
4.Date Well(s)Completed. L.Z�well ID# ft s ft VZ a?c-
5a.Well Location:
l ft CJ ft
�..p .�
A r
Facility/Owner Name Facility lD#(if applicable) kkb
It.
Zoo
ft
141 &�PmtA& �st�nr� ���«� ft ft
P}�'((cal Address,City,and Zip ft ft
-�
l` --` �• - - _ _ _ �- -tom 1.� nq
County Parcel Identification No.(PIN)
5b.Latitude and lone tude in degrees/minutes/seconds or decimal degrees:
(ffwellfield,one lQat/long is sufficient) r Q 22.C tification•
3� 0� 'N Id .31Do—` W
6.Is(are)the well(s)SPermanent or OTemporary Signa a ed a Contractor Da
'n is farm,I hereby ce;Wfy that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ^No w r 15A CAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction ififormation and explain the nature Dfthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back ofthfs 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: / 1 10 (ft-) 24a. For All Wells: Submit this form within 30 dayS of completion of well
For muluple wells list all depths)r&ff.-rent(example-3 00'and 2@I00D construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �L� above,also submit one copy of this form within 30 days of completion of well
(La.auger,rotary,cable,direct push,etc.) construction to the following: '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
P
13a.Yield(gpm) - Method of test: air pressure 24c.For Water SuuDly&Iniectiori Wells: In addition to sending the form to
a • the address(es) 'above, also submit `one copy of this form within 30 days of
13b.Disinfection type. W�� Amount:�� completion of well construction to the county health department of the county
where construt:ted
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2 22 2016
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