GW1-2022-10226_Well Construction - GW1_20221111

1.W ontractor 4galmation: L
14:.WATER ZONES :I_'• ;..s:: :: :....'; ':'.-.' '
Well CoLaq&ame FROM TO DESCRIPTION
ft $ I
-A ft ft �
NC Well Contractor Certification Number
` 15:0112ER IN mnlfi=6isedlivells)OR LINER(ifa'licahle}' ::':''
Morgan Well &Pump, Inc. FROM TO' DIAMETER TMCM ES5 MATERIAL
Company Name +1 f' ft 1181 sd21 pvc
. 1 —^ 16:7NNEI2 C' G OR•TDBING:' eotliermal ci6'sed loo'
2.Well Construction Permit#: FROM TO DIAMETER THICIGgEsS MATERIAL'
List all livable well construction ermits Le ft. ft in.
applicable p (' UTIC,Couaiv,State,Ymiance,etc.)•
in
3.Well Use(check well use): ft. ft
Water Supply Well: MSCREEY -. :::`:.: .`• < •.= _.:r_::;;:,:.•.• %",: t'.. ,:i:.;..,r. .n.;.:. .::<' .
FROM TO DIAMETER SLOT SIZE THICKNESS 14IATERTAL•
Agricultural C#Municipal/Public ft ft in. i
t :Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft in. I
17ndustnal/Commercial 1 Residential Water Supply shared -
PP Y )
( :GROUT•: -_,•
Irri ation FROM TO MATERIAL Y EMP -CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft benionite poured
Monitoring Recovery ft ft.
-Injection.Well.
_.!Aquifer Recharge K3 Cn oundwater Remediation ft ft
Aquifer Storage and Recovery Salmi Barrier '�i SAND/GRAVELTAAC tf a"hcabre
q g ery ty FROM TO MATERIAL -.,- L.,•. r.-`METHOD
Aquifer Test OStormwater Drainage ft ft.
f Experimental Technology DSubsidence Control ft ft . Uf*
�n Pr:>'c
i Geothermal(Closed Loop) Tracer :20.DRIL7�IG.L'OG'(attaclisdditioual sheets Mne7:,s
Geothermal(Heating/Cooliag ReMm) -�Other(explain under#21 Remarks) FROM tTO DESCRIPTION(mlo,hardness,soiUrock ty a in size,ete)
a .ft l0
4.Date Well Completed: bT10_Ir?2 Well ID# 0 ft. ft
5a.Well Location:
ft ft.
� ft ft
Facility/Owner Name Facility ID#(if applicable)
ft ft
ft ft
Physical Address,City,and Zi ft ft
:..
* 21 �22-(Y
6
County, Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q,,� ` 2 er ration
6.Is(are)the well(s) Permanent or [3Temporary Signa killgrtified Well Contractor Date
B o ung is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or f No wuh I5A C 02C.0100 or 15A NCAC Ok..0200 F7e17 Construction Etandmds and that a
Ifthfs is a repair,fill out known well construction information and expbun the nature ofthe copy ofthis record has beenprovided to the c ell owner.
repair under 421 remarks section or on the back of this 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 NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
drilled: t1 SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 4bv A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we1Ls list all depths ifdifferent(example-3 a 00'm,d 2Q100) construction to the following:
10.Static water level below top of casing: 51� (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 form to the address in 24a
12.Well construction method: r Q+_Q1W above,also submit one copy of this form within 30 days of completion of well
construction to the following.-
(i.e.auger,rotary,cable,directpush,eta)
L
WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
� the address(es) 'above, also submit one`,copy of this form within 30 days of
Disinfection type — Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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