GW1-2022-08569_Well Construction - GW1_20220503

— ---• ___ "� .,.. �..,� vxw �xvr-a I rorInternal Use Only:
I.Well Contractor Information: _Cn
06((U. ` �'�WC 14:.WATER ZONES
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Well Contra torName FROM TO DESCRIPTION r
� ! ,
NC Well Contractor Certification Number ft.
15.O=XP,--QASING.(f6r multi-dised we1Ls)bR TxgE,R(if'a"ucahle)'v
Morgan Well & Pump, Inc. I FROM I To DIAMETER TMUGMSS MATERIAL
Company Name +1 ft' ft. 6 118/ tn. sd2l pvc
16:INNER CASIN OR-TUBING. 'eottiermal closed rod' :.
2.Well Construction Permit I FROM TO. DIAMETER TMCMNESS MATERIAL
List all applicable well construction permits'#.e.&M,County,81ate,Variance,etc)• ft ft in.
3.Well Use(check well use): ft ft in.
VC=ther:mal
upply Well: 17_"SCREEN'. -
r.
FROM TO DIAMETER SLOT SIZE TrUCKMS MATERIAL.,•
ltural �Municipa]/Public ft ft in.
(I3eating/Cooling Supply) Residential Water Supply(single) ft ft in.
Commercial DResidential Water Supply(shared)
GROUT•:: =. .;:-:r/.c,+..,:�.:. .•.::='.:.:= v '•:.:. .,,.._: ..
ation FROM TO :MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: W--A-NfD/(;
ft- 0 R bentonite poured
Monitoring Recovery ft.
Injection Well:
�-} ft
Aquifer Recharge l=tGroundwater Remediation
Aquifer Storage and Recovery Salmi Barrier RAVEL PACK tf ii "Ticabre "1,C,. ::+:'.::_ , . ..'.•:_ -r . ,.:[:.'
ty -TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft.
1 Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) OTracer :20.DRILL@1G.]L'O9(attacIi`additional slieewf
Geothermal(Iieating/CooIing Return) J Other(explain under#21 ) FROM TO DESCRIPTION(valor hardness,sail/rack type,grain size,etc)
ft. � ft -�•
4.Date Well(s)Completed: �-Ot-t'/ Well ID# ft ZG1D ft
Sa.Well Location: S e7ft O A� ',4l5��rC ,
$1 rmoo O ft. Q ft ✓f y�'�C
Facility/Owner Name \ L /► 1Faac'ility E (if applicable) ft ft
� � \r1 Q!S C-� / '/'y (,gcard ft ft
Physical Address,City,and Zip ft ft
RAAXI
bn_' 1rf✓S •� `21i"Rti'MARTfS=' :',. `:i� _ - -
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
ri-
(ifwe fie d,one lat/lo is sufficient) 22.Certification' ,
5� 9O? N 86. 6-7 673 Z�
6.Is(are)the well(s)&ermanent or ©I(Temporary Signature of Certified Well Contractor Date
By signing this form,I her•ebv certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or f�6o wuh 15A NCAC 02C.0100 or 15A NCAC 02C..0200 Well Construction Standards and that a
Ifthis is a repair fzH out known well construction information and explain the nature ofthe 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:
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:- ' % 3 qc) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al!depths if different(example-3@200'apdR@100�
construction to the following.
10.Static water level below top of casing: 6 (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.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r O.-L-41 Y L� above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
i
FOR WATER SUPP ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: air pressure 24c.For Water SunDiy&Infection 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: 4A'r 011� Amount: G,L, 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
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