GW1-2022-05619_Well Construction - GW1_20220610

1.W o actor Infon:
1R. , V Vl/� 14:.W.4.TER ZONES:'. .�i:: '.,..�..�=::•':....'.•:'...-.,;
Well ontrw4udame FROM TO I DESCRIPTION
::Aft ft
ft ft I '
NC Well Contractor Certification Number
� '15:OUTER,eASINO,(foc iuniti=cased wlIls)O�2 LIIgE)t Cif'_ lirable)'s:�::`.'.::-•.`.;
Morgan Well& Pump, Inc. FROM T I DIAMETER TBIClaims I MATERrAX.
j I +1 ft ft. S 1/a/I rn' sdr2l pvo
Company Name 3l ��l :.:<.,.. t,,:
ld.`IlNATER CZ SING OI2•TUBING. •softie-r'mal_clo'sbd lou _
2.WeU Construction Permit#: C7 FROM TO DIAMETER THICKNESS MATEuAL-
List all applicable well constuction permits'(ie,WC,Cowttt,State,Ymiance,etc.)-
ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 12:SCREEN' .. +:,. . .. :-:.;'tt:. i.,r;i:.;•: ?.'K::.. .::;° .::
FROM TO DIAMETER SLOT SIZE TATCKNESS MATERIAL .
Agricultural DMuaicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) ft it in.
1 Industrial/Commercial J Residential Water Supply(shared) .`IKGROUT•:t
ftion FROM TO MATERIAL EMPLACEMENTMETHOD&.4MOIINT
ater Supply Well: 0 ft 20 ft bentonite poured
oring Recovery fL ft.
n.Well: ft ft
er Recharge Groundwater Remediation ,.-19.SAND/GRAVEL-PA:CK if a:%icabrb '
er Storage and Recovery DSalinityBarrier FROM TO • MATERIAL Ely2LACEMENT METHOD
er Test OStormwater Drainage ft ftmental Technology DJ Subsidence Control ft ftermal(ClosedLoop) OITracerrmal(Fieating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock a in s ze ete
4.Date Wells)Completed 1"1 Zell ID# ft S ft
5a It ovation• � S� o ft 'bV,0WN (- &V_ '
U4, Yyypy' " 66) ft ZOpit Au{. 1UJ'%
Facility/Owner Name Facility ID#(if applicable) ft ft K:h,, "•
0�5 �? dter Cyr 1, �2g1 :s . ,� ,.
icad Address,City,and Zip ft ft D022
466 '?C069
County Parcel Identification No.(PIN)
5b.Latitude andlongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 er cation'
W
6.Is(are)the well(s)*Permnnent or OI Temporary S' ed a ntractor Da
By sip ing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or KNo with 15ANCAC 02C.0100 or ISA NCAC 02C.0100 Nell Construction Standards and that a
Ifthis is a repah•,fill out known well construction information an explain Are nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarla 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: ' - I SUBMITTAL INSTRUCTIONS
O
9.Total well depth below land surface: Ja-L-1 -(ft-) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiierent(example-'3Q200'and 1@100) construction to the following:
10.Static water level below top of casing: M V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wens: In addition to sending the form to the address in 24a
12.Well construction method: CO�r LL
construction to the following:
above,also submit one copy of this;form within 30 days of completion of well
(i rotary,cable,auger,rota cable,directpush,etc.)
EDisinfection
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
Y 1636 Mail Service Center,Raleigh,NC 27699-1636
W Method of test: air pressure 24c.For Water SuDDly&Iniection'Wells: In addition to sending the form to
typeoNnn the address(es) 'above, also submit one copy of this form within 30 days of
orl nf, 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