GW1-2022-09269_Well Construction - GW1_20221003

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1.Well Contractor Information:
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kV1S IrUGit/� •14:.WATERZONES;•.
Well Contractor Name �BR-OM I TO DESCRIPTION
NC Well Contractor Certification Number 15:OUCER-edSIN�,(fn?multi=riled`weI]s)OI2 LQQER 11 a'Ticable)'V,:::'.'.:: '•
Morgan Well&Pump, Inc. : FROM TO' I DTd1ETER I THICKMESS MATE.RIAI,
Company Name +1 ft ft 6 i/BI sd21 pvc
IcmI tm C SONG OR-TUBING: 'eotliermal ciose3lod" _
2.WeD Construction Permit#:_�6�—Lb 96�� FROM TO DIABOM THICKNESS MATERIAL
List all applicable weft construr-ion permits'(ie.UIC,Cow4v,Stale,Variance,efc.} ft fL
3.Well Use(check well use): ft ft m
Water Supply Well: 17."SCREEN',= ,. ..:•°_ = i::. =r,.:.:;.:. .::
VROU TO DIAMETER•.-I SLOT SIZE •.THICICMS MATERIAL..,
Agricultural DMunicipa]/Public it ft in
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in,
I Tndustnal/Commercial UP
Residential Water Supply(shared) -
E Ini onI FROM I TO I MATERIAL EMPLACEMENTMETHOD&AMOMT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'Monitoring DRecovery ft ft
Injection Well:
J Aquifer Recharge K3 Groundwater Remediation ft ft r.• . : .
SAND/GRAVEL•PACg if•a"linable '.
Aquifer Storage and Recovery Salinity Easier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStornwater Drainage ft ft
t Experimental Technology OSubsidence Control ft ft,
Geothermal(Closed Loop) 13Tracer :2B.MRTLLINGZ OG'(atiaclis3difiona7 sheets aeces's"7': -r •'` r-�:::`%
Geothermal(Heating/Cooliug Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soillrvek a sia etz)
B ft 3a ftK'0A au
4.Date Well(s)Completed: ` c / Well m# i G ft
Sad-Well Location: �(r ft cS ft '? F _��•,
ft ft
Facility/QAner Name Facility IN(if applicable) ft ft C,
6S- fLT &W -L_ -f ft ft W
Physical.Address,City,4Zip ft ft Uri;
County ParcelIdentmcation.No.(PIN)
5b.Latitude and long tude m degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sutacient) r r 22.C cation:
35-bo 'N 1:4-d^Zb`1 W
6.Is(are)the well(s). •Permanent or OTemporary Si�ature o&CeME19 Well Contractor Date
By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance
'l.Is this a repair to an existing welt Q'Yes or INNo with ISA NCAC 02C.0100 ar,15A NCAC 02C.0200 MeU Construction Standards and that a
If this is a repair,frll out known well constuction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarlasection or on the backofthisform 23.Site diagram or additional well details:
B.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 bf wells construction details. You may also attach additional pages if necessary.
drilled:_ `� SUBIY=AL INSTRUCTIONS
9.Total well depth below land surface: 5�(tl ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For mula'ple we h list all depths ifdi erent(example-3Qa 200'and 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 casing,use•'+" 11 `1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) C 24b.For Iniection Wells: 1n addition to sending the form to the address in 24a
�f above,also submit one copy of this fomm within 30 days of completion of well
12.Well construction method: r 1 construction to the following:
(r.e.auger,rotary,cable,duectpush,etc.)
FOR WATER SUPPLY WEL LS,ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test air pressure 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
/���i� 2 the address(es) 'above, also submit one!copy of this form within 30 days of
13b.Disinfection type:l..Yl 0rShe Amount: 7J QZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016