GW1-2022-09252_Well Construction - GW1_20221003

ELL CONSTRUCT16N RECORD (GW-X) For Tntemal Use Only.
W
1.wen Contractor Information: e
14:. ATER ZONES . -T10N r
FROM TO � DFSCRIP
Well Contractor Name 7 ft 17-6 ft
35 ��R ft
NC well contractor CerlificationNumbei '15;07;ER:CdS1N�,(fo`r multi=riled swells)bRL (� licsl�le'-
Morgan Well&Pump, Inc. FROM To DiAMFTER; TM' 55 MA /3
+1 H• Z ft 81181 Lx' sdr21 pvc
Company Name ,µlJ ItR CASING &•OTOBII�G. eotTierrnal clo'se3lod'
r I'/t!�O O�� FROM TO Diet 't'i � THICHI�E55 .::•.MATEPJAL
2.Well Construction Permit#: ft. ft
List all applicable well constructionpermitr'(Le•V7C,Colaity,State,Variance,etc.)'
ft ft in
3.Well Use(check well use): •.:•` _ ,:::;•:.•i - r';,.: -•`•=.;�.:_:;.:. .::`
Water Supply'Well: FROM TO DIAMETER' SLOTsrzz :'Twclaiws MATE
gn RIAL.
A cultural C5Municipal/Public ft rn
Geothermal(I3eating1Cooling Supply) � ldential Water Supply{single) ft ft
Water Supply(shared)
I ustrlal/Commeaclal I Residential S uPp are ) D FROM TO >yL.4CEMFNTM=OD&AMOUNT
• MAT�Tet'
[ln-i ation '
Non-Water Supply WeIl: 0 ft 20 ft bentonfte• poured
Monitoring DRecovery ft. ft.
Injection Well: ft ft
J Aquifer Recharge MI Groundwater Remediation �:SAND/GRAVEL P9 CK zf a'lirable ..:::. :`::':'.::- ;• r ''
'Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL Fr—IP CEMENT METHOD
Aquifer Test DStormwater Drainage R ft
_Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [ITracer :20.DRILLINGS OG'(attaeh=additional sheefs�fnecess 7'' '':.1 ::'c;.:`
FROM TO KEE
ain s¢e,etc) .
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) D ft 46 ft
4.Date Well(s)Completed: _f_V- Well ID# ft 70
l ft ft52.Well Location: Z ft ftU ft ft.
Facility/ nerName F ID#(ifapplicable) _ ".,i
ZZ 36 = ,s �o ar`S ft ft
ft ft — t W
Physical Address,City,and Zip -- =,-:—•_ ".:;,
tj it
county Parcel'Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.5 off 'N _21 I SD g W Z5
Signaft= f Certified well Contractor Date
6.1s(are)the weIl(s) Permanetrt or Temporary
By signing this form,1 hereby certify chat the wells)was(were)construcrr�in accordance
Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 weII Construction Standards and that a
7.is this a repair to an existing well ©
Ifthis is a 2-Edon fill out known well construction information and explain the nature of the copy ofrhis record has been provided to the well owner.
repair under 421 remarks section or on the barb of thisform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary.
construction,only i GW-1 is needed. Indicate TOTAL NUMBER wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11st all depths 1fdiierent(example-3Q200'mu12@100) construction to the following.
10.Static water level below top of casing: tfT A) Division of water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" •1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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 fbim within 30 days of completion of wall
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VaLLS<ONLY• 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
132.Yield(gpm) 71 Method of test: air pressure 24c.For Water Suyuly&Tniection wells: In addition to sending the form to
1_ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type ���pVlh.� AmountCf7 completion of well construction to the county health department of the county
where constructed
I
Form Gw-1 Nortb Carolina Department of Environmental Quality-Division of water Resources
' Revise d222-2016