GW1-2022-10206_Well Construction - GW1_20221111

1.W ontractor mation:
14:.WATER ZONES ;
WellToonnt�f r ame FROM TO DESCRIPTION
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M ft ft {
ft. i,
NC Well Contractor Cet 4cation N,mbet
IS:OUTER,G�ASllIG,(formnlfi=r2sedweDs)b2LII3ER if iirohlE' :::`•'.;:' .`.:
Morgan Well&Pump;Inc. FROM TO' I DIAMETER I TIU MESS MATERIAL
Company Name +1 ft ft 61/81 I �' sdi21 pvc
GJ� JC_D I4ER G Ok•TOBING. 'eotliermal closed-Ioo"?.:':.:�''•;' :%.• '_ ,:. .
2.Well Construction Permit#}: J , FROM TO DIAMETER TI31CRI•IESS MATERIAL'
List all applicable we11 construction permits'(ie.UIC,Countv,State,Variance,etc)• ft. ft• in
3.Well Use(check well ase): fL ft m
Water Supply Wen: 17 SCREEN'.:::'''._- .`• r •.:•`_ - - .(;;:,,:=:-?• "�::..
A lcnitnral FROM TO �.DIAMETER •SLOTffiZE .TrrrcKNws MATERTAL. .
gt DMunicipa iTublic ft fL
b i Geothermal(Heating(Cooling Supply) J#Residential Water Supply(single)
ft fc in.
I TP„st„ai/Commercial J Residential Water Supply(�4 -N.
-
;18:GROUT. `
:lei alioo FROM I TO I MATERIAL +CEIaNTMETROD&AMOIM
fNter Supply Well: o ft 20 ft bentonite- poured
ring Recovery ft. ft
.Well: R fL
r Recharge 0 GroundwaterRemediation
�;�, ;19:SAND/GRAVEL'PA.CK tf a 'linable :;. `:;;r Storage and Recd�ery. Salinity Basier FROMTO MATERIALT METHODr Test OStomiwater Drainagemental TechnologySubsidence Control fR ft
mal(Closed Loop) OTracer :28.DRUXING.L0G'(httich'iddiddii it AeeItid'necegsmal eating Coolie Return Other FROM TO DESCRIPTION cola,hardness,soiltrock type,grain size,etc)
(H e g ) (explain under#21 Remarks)
,' b 2.0
4.Date Well(s)Completed: WellID# 20 ft %0 ft
Sa Location: () R p
6 ft ft ra
L r Facility/Owner Name Facility ID#(if applicable) ft ZO
AN6�m �1
Physical Address,City,and Zip ZSSo3 f ft ft
to A%\ {o °21i R17M}RKC�:. ':' '`:i _ /11f
__S%
County Parcel Identification No.99
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(If Fell field,oneellat//l�ong is sufficient) o n 1 a 2 ration:
N D� . t d- 1 W /L✓
6.Is(are)the well(s)*Permanent or ©ITemporary Siva rtified Well Contractor Date
B e ing it form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or AN.�Nc wuh ISA C 02C.0100 or I5A NCAC Ok-.0200 WeII Construction Standards and that a
Ifthis is a repair,fill out)mown weII construction iriformarion and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the bark of this form 23,Site diagram or additional well details:
8.For Geoprobe/DPT or CIosed-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.
, !1l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All WeIls: Submit this form within 30 dayt of completion of well
For multiple wells list all depths ifdiierew(example-3 cr 00'and 2@100� construction to the following.
10.Static water level below top of casing: 3S A) Division of Water Resources;Information Processing Unit,
Af,water 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 fn=to the address in 24a
(12.Well construction method: above, also submit one copy of this fowl within 30 days of completion of well .
~ )� LI construction to the following.
(Le.auger,rotary,cable,direct push,etc.) I•
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
'
13a_Yield(gpm) Method of test air pressure 24c.For Water SuppIy&Iniection W i ells: In addition to sending the form to
the address(es) 'above, also submit one'copy of this fog within 30 days of
13b.Disinfection typ Amount: �$�Z 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 WaterResources Revised 2 22 2016
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