GW1-2022-05825_Well Construction - GW1_20220609

I.Well Contractor Information: L I
14:.WATERZONES:'. :I: r.:= :....".'•..._..:. - ..
Well Contractor Name _' FROM TO DESCRIPTION
� f
NC Well Contractor Certification Number
15:OUTER C�ASINts,ioc rnniti=rased;ovells OR Lml=(if- licahle'.;
Morgan Well &Pump, Inc. FROM TO' DLAMETER THIcKNEssI MATERIAL
Company Name
+1 ft ft 6 1/0/1 � in. sdr21 pvc
Id:IN ER CLSING OR TUBING.' eothermal closed lod' ,:
2.Well Construction Permit#: 1 v, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consP uction permits'fl.e.WC,Comity,State,Variance,etc.)• ft ft in.
3.Well Use(check well use): R ft. in.
Water Supply Weil: IZ-SCREEN',
FROM TO DLAMETrs'12 SLOT SIZE THICKNESS MATERIAL.
__'.Agricultural �MunicipalRublic ft. ft in.
I Geothermal(Heating/Cooling Supply) O"i Residential Water Supply(single)
••
ft. fL
ITTaI Commercial J Residential Water Supply(shared) GROUT-.'-. - ' - -
I Ini ation FROM TO I MATERIAL EMPL.ACEMENTMETHOD&-AMOUNT
Non-Water Supply Well: o ft- 20 ft bentonits poured
'•Monitoring Recovery ft ft
-Injection.Well. ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery DS&LinityBarrier 'FROM
SgND/GOvEL'PACK tf TERML ~; J EMPLACEMENT iY1E'1'HOD
Aquifer Test Stormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) OTracer :20.7)RILLING.DOG'(attacti'additional s7ieetsjf aecess "
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(mlo,hardness,soiUrock type, size,etc
c r Q ft ft
4.Date WeU(s)Completed: ��� ��Jell ID# 0 t- 4�ft rb / '
5a.Well Location: ft ft. �Gl't
(�A A0� 40 eft ft AW
/A
Facility/Owner Name Facility ID#(if applicable)k\1 Q� �4-
e / �` ft "r~
Physical A tddrem,City,and Zip , fL J U N 0
V" � - �V �� `•2k-RF.M6RKR= 'i.'. - `:r _ _ _ :,.:..�4_.''. !.:•:E•'::_'a:j.:`.,..
County Parcel Identification No.(PIN) 4� DD�I 0;>� •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' tion•
17 N0© r ZQ w
6.Is(are)the well(s) Permanent or 13Temporary Si, tore of Certified Well Contractor Date
By signing this form,I hereby ceeti;5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Mo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair-,fell out known well construction information JnYerplain the nature ofthe copy ofthii record has been provided to the well owner.
repair under#21 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 I GW-1 is needed. Indicate TOTAL NUMBER&wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: / (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlferent(example-3 tt 00'mi 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 casi,:g,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) (( 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r LI above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct puslr,etc.) '
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
/ f
13a.Yield(gpm) ` Method of test air pressure 24c.For Water Supply&Injection.Wells: In addition to sending the form to
the address(es) 'above, also submit!one copy of this form within 30 days of
13b.Disinfection type: /' I Amount: e �� completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016
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