GW1-2022-08624_Well Construction - GW1_20220906

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1.Well Contractor Information: I :
�0.� �C V •14:. L.TMZOISES -
Well ConlractnrName FROM TO DESCRIPTION
(� f ft ft
7 c aC.J�o ft ft
NC Well Contractor Certification Number
•15:OUTER_G�dSIN�,(fac multi=rased wens)OR LII�t Crt'_.Iicable)'1:�::�.:_'•.`.-
Morgan Well &Pump, Inc. FROM TO. DIAMETER TIR( ESS MATERIAL
+1 ft, ft 61/BI M. sd21 pvc
Company Name
^ �•/ 16:Il�R CriSING OIt•TfIBIi�G. eottiemaZ'cIn'sed-moo"?. "':._• :;.:�':••:_'•; -
2.Well Construction Permit;r: !J q FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(Le.Ultra Cowdy,State,Variance,etc.)• ft. in.
3.well Use(check wen use): ft. �t m
Water Su 1 WeII: . 11-SCREEN',::.. `:;. .`� '.:•=•.: :,:;:; :�;,.::.;::.::-�.: ;;•'...:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) i Residential Water Supply(single) ft ft in.
IndustnaUCommercial I Residential Water Smipply(shared) - r..•� .:._.-_ ._. ...;: :'::- "-;;
I hrigation FROM TO I MATERIAL _ EMPL-4CEMENTMETHOD&AMOIINT
Non-water Supply Well: o ft. 20 ft bentonits- poured
Monitoring Recovery ft ft
Trajection Well:
ft ft:
__!Agmrifer Recharge Groundwater Remediation
,.'19:SAND/GRAVEL'PA!:x rt a"licablb
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
—!Aquifer Test OStormwater Drainage ft R
N1,
Experimental TechnologyOSubsideace Control ft. ftGeothermal(Closed Loop) Tracer :ZB.'DRILLING.TOG'(atticli ddid*"' sheets,dfnec -j'ess" .,M To DESCRIPTION(color,hardness,snillrack type Geothermal(Heating/Cooling Return) Other(explain under 921 Remarks) FRO gra n s ze etc)
.ft ft
4.Date Well(s)Completed: r�'� Well ID# Q
Sa.Weil Location: ft ft. _
an �;L'P 11 ft 9 U (dn t� _ r
7
Facility/Owner Name Facility]D#(ifapplicable)
agRS, e'yer;a 0 ft f>. SEP* 0 7n�
ft. ft
Physical
73
ra�Address,
��City,and Zip %Olq
ZIE i.•-
hot y8Q
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I^rfwerrll field,one lat/long is sufficient) 22.Certification: e� �j
qL
6.Is(are)the well(s) lPermanent or ©ITemporary Sim eofCertifie eHContrector Date
By sio�ung this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing weIl: D'Yes or No with 15ANCAC 02C.0100 or 15A NCAC 02C•.0200 Fml Construction Standards and that a
IJthis is a repay,fill out(mown well construcrYon information and explain the nature ofthe copy ofthis retard has been provided to the well owner.
repay under 421 remarks section or on the back ofthisform.
• 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 NDMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1.�00 ( ) 242- For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii&-ent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: (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 Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form witbin 30 days of completion of well
12.Well construction method-. C Q Ir L` construction to the following:
(Le.auger,rotary,cable,directpush,eta) J -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY MLLS,ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) ( _Method of test: air pressure 24c.For Water Supply&Ini6ction 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- Amount: G.5 Z completion of well construction to the county health department of the county
where constructed.
Form OW-1 Nortb Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-�2 2016