GW1-2022-06252_Well Construction - GW1_20220701

I.W on
tractor Inf nation:
14:.%&TERZ0NES:•, - -
well Co for ame FROM TO DESCRIPTION
� ft ft
ft.
NC Well Contractor Certification Number
15;OUTER-CA,SING,(fo-r mnlii=casea wells)09lMiER(if .licable)'v
Morgan Well &Pump, Inc. FxoM TO. DIAMETER THIC)fYi ESs MATFRTA-T•
Company Name +1 ft ft 61/a/ in. sd21 pvc
16:INNM CASING OR•TOBII�G.'•eotfiermal closed-loo' ?.::;'-.._• :-:.' ' . .
2.Well Construction Permit#: �(/r V J� FROM TO DIAMETER TMCI(FSS MATERTAL-
List all applicable well construction permits'(u.e.UIC,County,State,Variance,eta)• ft ft m'
3.Well Use(check well use):
ft ft in.
17_-SCRET NN'.=:: :. -_:.••..- r ..- ;_: - : :
Water Supply Well: Mom TO DV143TER ' SLOT SIZE 'TWCKNWS �MATmuT..
J Agricultural DJ Mnnicipal/Public ft f- in.
Geothermal(Heating/Cooling Supply) JIResidential Water Supply(single) ft " ft in•
1 Industrial/Commercial i Residential Water Supply(shared) _
:18.GROUT. -
Iiii ation FROM TO MATF.RTAL - SMPL_4CRN7M1YIETEOD&AMOTINT
Non-Water Supply WeII: 0 ft 20 ft bentcnite poured
Monitoring Recovery ft. ft.
Jnjection WeII: ' ft ft
J Aquifer Recharge Groundwater Remediation
;.-B:S230/GRAVEL-PACK if a' -ckbne
'Aquifer Storage and Recovery USalmity Barrier FROM TO MATERIAL EMPLACEMENT RIMOD
—1 Aquifer Test E38tormwater Drainage ft ft
1 Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) r3Tracer :20.tiRILLINGI OG'kftkclisddition'sI sfieets aeces's
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saillmck type,a:.dn size,ere)
O ft ft
aA
4.Date Well(s)Completed: 23LIZ
Well ID# s ft S5 ft
s 5
Sa.WeII Location: ft.
�y ft '
4A %&\; ft ft
Facility/Owner Name Facility ED#(if applicable) ft ft.
JUC.Zowi ft.
Physical Address,City,and Zip ft ft �EUZZ
g�
�id �i V\ �j1;•R7`M:dRTIR`� - `:J _ _ _ 'z-• :`;� ;_.;:-. -
County Parcel Identification No.(PIN)
UL O S
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufncient) �(wiii tau_ rr,t+^ ,;
CZ72__��>
",�..crc t.LnW4
2
6.Is(are)the well(s)*Permanent or DITemporary Signs e f rtified Well Contractor Dat
B e ring is form,I het eby tech,fy that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or #@No wuh ISA C 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
Ifihis is a repair fill out known well consDruction information and explain the nature of the copy ofrhii 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'of wells construction details. You may also attach additional pages if necessary.
drilled:_ * . I SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface:75 (fL) 242.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifaYfferent(erample-3(a 200'and 2@I00) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) f 24b.For Injection Wells: In addition to sending the foam 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
construction to the following:
(Le.auger,rotary,cable,d rectpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1 _ 1636 Mail Service Center,Raleigh,NC 27699-1636
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 typ Amount: 6?i 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