GW1-2022-08195_Well Construction - GW1_20220503

1.Well Contractor Information: I f
Cti,dls MCIElao
•14:.WATER ZONES-;'. .•: ,� I':_'...��..��:i'';.,. .'.•:'...-:.:, _ ." . .:. - ..
Well Contractor Name FROM TO DESCRIPTION
S-72-- gs ft 1 166 ft Ik
ft ft
NC Well Contractor Certification Number
15:OOTER-GASIlIG,(foc multi-rased wells)O_MlER(tf`4011cahle)'!
Morgan Well &Pump, Inc. FROM TO' DIAMETER Mi TE[Ea = MATT.MLAL
+1 ft' ft61/8/ ! • in. sd2l pvc
Company Name
92 1G."Il�rER CASING OR•TIIBIIVG: •eotiie'r`malclo'sed-rod' :
2.Well Construction Permit#: / V 9V3 FROM TO DIAMETER THICENEsS rI MATERIAL
List all applicable well constructionpermits'(ie.WC,Count,State,Ymiance,etc.)• fL ft• in.
3.Well Use(check well use): S. ft in.
1VSCREEN'.:-'.: :.••.: i - =':i;. - :
Ed
pply Well: i:'ROM To DIAMETER SLOT SIZE TETCKTMS TVIATERTAL.'
tural DMunicipal/Public ft ft in.
mal(Heating/Cooling Supply) �idential Water Supply(single) ft ft in.
Commercial J Residential Water Supply(shared)
GROUT-.`-."
lai ation FROM TO MATERIAL - EPOI ACEIVIFSTT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 fL bentonite poured
'•Monitoring [3Recovery ft. ft
Injection Well: ft ft
__I Aquifer Recharge K3 Groundwater Remediation ;
�, •.19:RAND/GRAVEL-
Aquifer .:•. •..:•,� .. : '•.. :�'
Storage and Recovery r=9 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRTILING.I OG'(attacli'addition'al sheetsaf neces's" )':' ';'•`.'= -=
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soel/rock type,grain size,etc)
ft. eevft.
4.Date Well(s)Completed: '1Z-Z9, Well ID# ft ft
ft ft
5a.Well Location:
((�
/12Q Y��'• �f ll"►1+L��,,I \ ft ft
Facility/Owner Name A�1 Facility M#(ifapplicable) ft t f
cJJ� Uk�tcWoD� On ./✓�T l7Dfiti Ab� ft ft
Physical Address,City,and Zip ft ft
(�A+$,tCln
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Cer" ratio
35,31 Q35� -N W
'
6.Is(are)the well(s)�rmanent or Oi Temporary Signature o C e$Contractor at'
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 090' with 15.4 NCAC 02C.0100 or 1S.4 NCAC 02C:0200 Well Construction Standards and that a
If this is a repair fill out known well construction Deformation and explain the nature Dfthe copy ofthrs 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 1 GW-1 is needed. Indicate TOTAL NUMBER"of wells construction details. You may also attach additional pages if necessary.
drilled: tl SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �j (ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths efdii ferent(example-3@200'and 1@100q construction to the following.
10.Static water level below top of casing: 2� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
(( above, also submit one copy of this&rm within 30 days of completion of well
12.Well construction method: c d]Tr LI construction to the following:
(Le.auger•,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) / air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Q Method of test g
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: 40 Amount: Oh l ci & completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016