GW1-2022-07346_Well Construction - GW1_20220808

1.Well Contractor Information: I ,,
�a`/ ►C'3t� •14:. ATERZONES I;_
Well
lCContractor Name FROM TO DESCRIPTION c
NC Well Contractor Certification Number
� '15:ODTE&C4SING',(fo"rriiniti=rasedvteIls bRLIlJEA Cif_tiralile}'.�
Morgan Well&Pump, Inc. FROM TO' DIAIvDLTER THICIL�ESS Mi1TER7AL yi
Company Name +1 ft- ft 61/8/ 1 m' sd21 pvc
2Z- n ' 16.`A II�t G OR•TIIBlI�G. i eotfierma7
2.Well Construction Permit#: `V FROM To DL 1YIETZR THI(�ESs M 4TERTAL
List all applicable well constructionpermits'(ie WC,County,State,Variance,etc.), fL ft in.
3.Well ft Use(check well use): ft in.
;
I7:SCREEN'';'.
Water Supply Well: >RDM TO DLk1VfETZJZ I SLOT SIZE I^T15ICiOILSS 14rATERW .'i
-Agricultural rjMunicipal/Public ft ft in
I Geothermal(Heating/Cooling Supply) :Residential Water Supply.(single) ft ft .
Indus Commercial J Residential Water Supg13_(shamd) _ ,•a.-c.:_... -
::18:GROUT-.'--. ._._
i Iai lion FROM TO I,MATERIAL T'dtPL-4CEMENT METHOD&_4MOUNT
Non--Water Supply Well: 0 20 ft_ bentanite poured
Monitoring Recovery ft ft
Injection Well:
ft ft
er Recharge 13 a-oundwater Remediation 79:SiD/GRAVEL'PACK rf a"licaile)Aufefr '•
Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT IYETHOD
Aquifer Test 0 Stormwater Drainage ft ft
Experimental Technology QlSubsidence Control ft
Geothermal(Closed Loop) Tracer :ZO.DRILLII�TGS OG'(atfaclidditiGrisl sheetsjdnecess'
FROM TO DESCRIPTION(color hardness,soil/rock e,grain size,etc)
z Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) FROM
It O /town
4.Date Well(s)Completed: Well M# ft 167 ft' 64%�
Sa_.W4 Location:
ft fCl/L( v
ft. ft
Facility/Owner Name d t Facility M#(ifapplicable) ft. ft. } �`" g ��
am's Oen/k;4e,, , Qc ft ft. AUG
PP/h'"ysicalAddres,Ccity,and Zip ft ft
ann
11/`��1 / �J17 ZI:�x�:nreuus'..' ':�.;:--:-:1-•.::' .:.�fi#i.fi,• :} .'z:: ' y .y;'::T
County Parcel Identification No.(PIN) e .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/llong is sufficient) 22.Certification•
?�J✓ l l�2 N —3 5� 7 � W —
6.Is(are)the well(s)RPermanent or OTemporary, Si a Ce a ntracto Date
By signing this form,I hereby cerify t than the well(s)was(were)construcrerl in accordance
7.Is this a repair to an existing well: ©Yes or []No with 15A NCAC 02C.0100 or 15A MCA 62C•.0200 mell Construction Standards and that a
Ifthis is a repair,fill out known well consti•uctton information and explain the nature of the copy ofthis 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:
S.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.
dried.— SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiierent(ezarnple-Y@200'and 2Qa 100) constriction to the following.
10.Static water level below top of casing:_ 1 (ft.) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casiiwg,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
��
�L . above, also submit one copy of this form within 30 days of completion of well
12.Well construction method construction t0 the following:
(r.e.auger,rotary,cable,direct pusb,etc) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY TVELLS14ONLY: 1636 Mail Service Center,'RaIeigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection 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: a ' Amount: completion of well construction to the county health department of the county
where con§tmoted
Form GW-1 North Carolina Depaztnent of Environmental Quality-Division of Water Resources Revised 2 22 2016
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