GW1-2022-08580_Well Construction - GW1_20220503

ror ID=al use Vn1y:
1.Well ontractor Information:
14:.WATER ZONES
wellConhac :Name FROM TO I DESCRIPTION
NC Well Contractor Certification Number ft ft
15;OUTJ0,G�AS1NCr,(foc multi=cased'wells'O 2IJ13ER(if'a'ticahle}' `:`:.:; `
Morgan Well&Pump, Inc. FROM I TO' I DLUI TIER I 'I TmclaNFSS MATERIAL
Company Name +1 ft ft 1 61/8/ in. sd21 pvc
16.A IINEIt G Olt-TIIBII�G.' 16tlierm2[l cldse&lud'
2.Well Construction Permit#: FROM TO. DIAMETER ; I TRICKINESS I MATERIAL
List all applicable well construction permits'(4e.UIC,County,State,Variance,etc)- ft ft in.
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3.Well Use(check well use): ft ft in.
Water Supply Well: 1 SCREEN'.= - =` _ :. ::=.;•:r.-
FROM TO DIAMETER SLOT SIZE .THICKNESS MATERIAL.
Agricultural CIMunicipal/Public ft %
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
I Iudustdal/Commercial E3Residential Water Supply(shared) iYSrGRODT::, ' _ _ , ? °}•:r='
ation FROM TO MATERIAL EMPI Ar,CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL bentonite poured
Monitoring QRecovery ft ft.
Injection Well:
ft ft
Aquifer Recharge 13GroundwaterRemediation r.
`Aquifer Storage and Recovery t Sa]ini Barrier �:SAND/GRAVMPACK if a'llcibli
ty FROM -TO MATERIAL E1�LACEMENTMETHOD
__Aquifer Test QlStormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) 13Tracer :20.DRUIDNG.DOG'atticliaddition-ilsliefsjfEiEess �'. —
LJ' ( -7'
I Geothermal(Heating/Cooling Retum) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain s ze etc
ft ft06!
4.Date Well(s)Completed: / Well ID# ft ft. rt7
SR. ell
L,ol�tion 0 ft U ft /L
Facili�{(Ow� �Na�te ( FraccilityID#(ifapplicca'ble) f ft 04 ft.
''/lLL /(l„JS ���i-'oU c!• V t Q V (J�/!cu rU ft ft
Physical Address,City,and Zip ft ft
2Y6 .r
County Parcel Identification No.(PIN) _
n �(
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell ld,one sufficient) �p q 22•Certiff n: 0 2027
K. N gn . 66 l>y W
6.Is(are)the well(s)&ermanent or Qlf Temporary SignatureofCertified Welf Dale
((�''42 ,I.1 all,
By signing this form,I hereby certify that the Well(sIwas f were1constructed in accordance
7.Is this a repair to an existing well: M'Yes or Vo with 15A NCAC 02C.0100 or ISA NCAC 01C•.0200 Well Construction Standards and that a
Ifthis is a repair fr11 out known well construction information and explain the natw•e of'the copy ofthii record has beer:provided to the well owner.
repair under 421 r•emarla•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: - % 560 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 if different(example-3Qa 200'and 2@1 00)
`/ construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
1617 Mail Service Center,(Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this for within 30 days of completion of well
12.Well construction method: 0 construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
FOR WATER SUPP X WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
FOR WATER STJP7Y WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 - Method of test: air pressure 24c.For Water SuuDiv&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 type: [i J Amount: U'V completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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