GW1-2022-09258_Well Construction - GW1_20221003

T rA2JA�JJ l.lJl`I ll A JllU l:I.ALVIY M UU" (U W_J) , I'14or internal use unly.
1.Wllontractor Information:
14:. 1sTER ZONES r.:
Well Contractor ame FROM TO I DESCRIPTION
fL ft
' JQ„ ft ft � .
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NC Well Contractor Ceitifi 'on Number
'15:OUTER:G%dSWG,(fnc multi-.rased wells OR_imilm Cif-'liciWe' :•:: .'.:
Morgan Well&Pump, Inc. FROM TO' DIAMETER Tfficr�isss lrrsTExrar
Company Name +1 ft 61/B/ I in.
sd21 pvc
16 R CASING OR•T(JBII�G: 'eotfier'ma1'cla' -mod'
2.Well Construction Permit#:_[ G FROM TO DLOOTER' THICKNESS MATERIAL
List all applicable well construction permits'(i_e. UIC,Cmaity,State,Vmiance,etc.). R ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17._SCREEN',:..
FROM TO - DIAMETER' SLOT SIZE THICKNESS MATERIAL.
J Agricultural QMunicipal/Public ft ft ia'
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft ft in.
laHit-n Commercial _Residential Water Supply(shared) $ Dom• $._EZ:n-Water
ation FROM TO MATERUL maU.CEMENTMETHOD&AMOUNT
Supply Well: o fL 20 ft bentontte poured
onitoring DRecoveiy ft. ft
Injection Well: ft ft.
J Aquifer Recharge [I Groundwater Remediation '19:SAND/GRAVEL•PA:M if a blickbre
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EIAPLACEMENT iIMHOD
J Aquifer Test �J Stormwater Drainage ft ft.
i Experimental Technology OSubsidence Control ft ft
i Geothermal(Closed Loop) Tracer :20.DRIIS�TGS OG'(kttact'sdditionaI seetsnecess �'::; --
Geothermal eating Coolie Return J Other FROM TO DESCRIPTION(color,hardness,:oil/rocktppe,grain size,etc.)
t (Heating/Cooling�/ g ) (explain under#21 Remarks) ft . J'
4.Date Well O ft s)Completed: ID# o• ft So ft
5a.Well Location: C ft 15 ilr6 t� (�O
(,W L .a, '71 ft L k ft. r
Facility/Owner Name Facility M#(ifapplicable) ft ft
AOe D� ft ft
Physical Address,City,and Zip
ft ft
it;MEMARKS 7_ :J. _ J �..6•: 'c :fir..'...:•:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I �:i
(ifwell field,one lat/long is sufficient) 1 1 22.Certification:)
6.Is(are)the well(s)Vermanent or O'Temporary SignatulfeofCertilied Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or tNo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 F7ell Conshvction Standmds and that a
If ibis is a repair,fill out known weAconsn•uction idformation a d explain the norm a of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
S.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 ifnecessary.
drilled: 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 fist all depths if different(example-3 a 00 muf 2@100D construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection'Wells: In addition to sending the four to the address in 24a
L� .4ove,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following
(Le.auger,rotary,cable,directpush,etc.)
[FOR WATER SUPPLY WELT—Q,ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
a.Yield(gpm) PS Method of test: air pressure 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
b.Disinfection type: 6­140 f 11 Amount: 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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