GW1-2022-09247_Well Construction - GW1_20221003

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1.Well Contractor Information: r
3 CW (3 Q 14:. ATER ZONES.:*,
Well Contractor Nalae FROM TO I DESCRIPTION
ft ft
ft ft
NC Well Contractor Certification Number
15:OUTER CASING,(&irhulti-rasedfveDs)b zLIIiER rf' tirah7n .g: •.
Morgan Well &Pump, Inc. FROM To. I DIAMETER I THICM\ESStIVIATERIAL
Company Name +1 ft ft 61/81 sd21 vc
W D J� Ib IlTAR G OI2•TIIBING. 'eotliermEd erased loo'
2.Well Construction Permit4,�i (i� TU ADM TO D11NANG,TER TMCSNFSS MATERl4L
List all applicable well cons0wctionpm7dU'rLe•UIC,Cormtr;State,Variance,etc)• ft
3.Well Use(check well use): it. ft m
Water Supply Well: 11-SCREEN',r:.. ;. .`�v ._•_.:_ :,..:.•i:;:: :: ',.: `:•:.1 :;.:. .:::° .:,
FROM TO DIAMETER SLOT SIZE THrCKNESS MATERIAL
Agricultural 0i Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
Tndustn Commercial OResidential Water Supply(shared) :8 (SROIJT,•. "`: _ _•:,• •_.,: .::..:- ...:.. - -
MInigation FROM I TO I MATERIAL LWT-ACEMENTMETHOD&.4NIOIINT
Non-Water Supply Wen: o ft 20 ft* bentonfte poured
'monitoring DRecovery ft ft.
I(Geothermal
jection Well: ft ft.
Aquifer Recharge KI GroundwaterRemediation r.
A for 5tora a and Recov �:��/GRAVEL•PACK rf a"licabie •qui g ery DSalinityBarrier FROM TO MATERIAL EMpLACEMENTMETHOD
Aquifer Test [3StormwaterDrainage ft• fL
Experimental Technology Subsidence Control f, ft
Geothermal(Closed Loop) TracerFROM TO DESCRIPTIeedON(cola,hardness,sail/roekty e,grain size,etc)
(Heating/Cooling Retain) -i Other(explain under#f21 Remarks) ft Q ft
4.Date Well(s)Completed: r Well ID# 'a. ft D ft
52.Well Location: ft 'a ft' 09W C
it �rA Der' aft oCqt
Facility/Owner Name Facility IDV(if applicable)
ft ft
ee
f^ ft ft.kAJr:=
Physical Addrra! Cii y,,and Zip ft ft
-
Coyty ParcelIdentificationNo.(PIN) -
r \�ei
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(ifwelll field,one lattlong is sufficient) 9 i Q�1 22.Certification:
a ,� T77 (� N_ --ItlW W `l Z.
6.Is(are)the well(s) Permanent or Temporary Sim Certified WeH Contractor Date
�.�( By signing this form,I hereby cernfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Xes or ( No with 154 NCAC 02C.0100 or 15A NCAC 01C.0100 WeH Construction Standards and that a
IJthis is a repair,fill out known well construction information nd explain Une natty a of the copy ofthii record has been provided to the well owner.
repair under 421 remarks section or on the back ofthis 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 NU OER'of wells construction details. You may also attach additional pages if necessary.
dried. SUBMITTAL INSTRUCTIONS
t)
9.Total well depth below land surface: Ton (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths ifdifferent(example-3 c/�2,00'and 2@100) 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.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method 0 �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:
FOR WATER SUP PLX WELLS�ONLX Division of Water Resources,Underground Injection Control Program,
• 1636 Mail Service Centr,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Water Suppiv&Injection Wells 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: 0'�Iwl Amount: C, 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 - i Revised 2-22 2016