GW1-2022-07343_Well Construction - GW1_20220808

1.Well Contractor Information:
-14:. ATERZONM
Well Contractor Name FROM TO =DESCRLPTION
ft
NC well Contractor Certification Number
'15:0137ER: 3wells ORLIIgER tf licahle' ::::•.•: '-
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICK`IESS MATERrnL
Company Name +1 ft. gy ft r,vai I in' sd21 pvc
r 16:II�R CASING OR•T(1B1NG' eotfie"r'ma1-closed-loo• '.`:..":..a• .::'•,.•,.� -
2.Well Construction Permit#: 3j�1/ FROM TO DIAMETER I TMCKNESs I MATERIAL
List all applicable well construcdonpermits'(Le.WC,Cowity State,Fat-once,etc-)- f, ft m
3.Well Use(check well use):
ft ft in.
Ja,tge,Supple Well: FROM TO D SLOT size THicKNws MATERIAL.
Agricultural cLpal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft ln.'
id striavcommercial J Residential Water Supply(shared) :18: *'GROUT• .. _, -_•, ,. : .
ini ation
-
FROM I TO I MATERIAL EMPLACEMENT MOUNT
Non-Water Supply Well: o R• 20 ft bentonite poured
Monitoring Recovery ft ft
Injection Well:
Aquifer Recharge Groundwater Remediation ft
'Aquifer Storage and Recovery Salinity Barrier ,F�ROM TO I A�/GRAVEL'PACZC •able ....:=.. -`;:'i� MENTiYlETHOD •.
_ IAL EMPLA
Aquifer Test 0StormwaterDrainage ft ft
_Experimental Technology OSubsidence Control ft ft
rGeothermal(Closed Loop) OTracer :20.tiRiLLINGSOG'(attach=additionsIslieefsifnecess -j"::
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiurock e,ft-
4.Date Well(s)Completed: r2 Well ID# ft k - '�Sa.Well �Lj
Location: ft6 r�ft
Facility/OwnnerNamee P�� Facility IDN(ifapplicable) ft
-L S 1 ev�,y(�i�lr 1dlr( Gc' ft ft
Pb yss;a1�/Ayddres�s,City,and Zip ft ft
rl (/l N'l�'{rY] ''ZI:'Rl�.MeRUR=-- _ - -:,•- I _ - - - _x°�.:- -
county Parcel Identification No.(PIN) A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ED
(ifwell field,one lat/long is sufficient) 22.7art—ification,1
6.Is(are)the well(s) i?ermnnent or OTempoWo
Signature ofCe ' ed .tractor it 1wn P` e""" `
D%!Q180G
By signing this form,I hereby certify that'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or with 15.4 NCAC 02C.0100 or 15A NCAC 02C,0200 Mell Construction Standards and that a
Ifthis is a repair,fill out(mown well consb•uction information and erplain the nature ofthe copy ofth i record has been provided to the well owner.
repair under 421 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 1 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 land surface:
P � � (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11st all depths ifdifferew(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: �� A) 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.) 24b.For Iniection Wells- .ffi addition to sending the form to the address in 24a
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 Y LI construction to the following:
(Le_auger,rotary,cable,directpush,eta) J '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEL—Q,ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
i a the address(es) 'above, also submit one;copy of this form within 30 days of
13b.Disinfection type: Cupl�tj� Amount: /02 completion of well construction to the county health department of-the county
where constructed.
I
Form Gw-1 North Carolina Department of Environmental Quality-Division of water Resources - i, Revised 2 22 2016