GW1-2022-10717_Well Construction - GW1_20221208

Well Con for erne.
ft I
�J•�•� ft ft•
edweDs b12LI�C�a lirable'�:'.:>.•- '-�
cation Num6et '15:OU -CAS G•(foi•mnitL�� TxCjaTESS MATERr1iL
NC well Contractor Cer FROM TO
Morgan Well &Pump;Inc. +1 ft. 61 0/ Sdrzi P°°
e0tiierma7closed lou`?.`•:•�s
Company Name 16 MOR CASING O&•TfJB laoTZR TIEnaC gg MATERIAL
7A< 1 U� FROM TO in.
2.Well ConstrnctionPermit#: ft ft
List all applicable well construction Permits(Le.WC,Coutuiv,State Ymzmice,etc) ft ` in
3.Well Use(check well nse): 1't••SCREEN•=•.: Dra,1Vi'ETER, •SLOT SrZE ffi
. •~TCKNESS �IviATL.
FROM TO
Water Supply Well: ft. ft in.
Agricultural _ 01 Municipal/Public
Geothermal(Heating/Cooling Supply) IpResidential Water Supply(single) ft ft
b 1 lndustn Commercial i Residential Water Supply(shared) ;18:GROUT'.:.• - - "MATERrer.
FROM TO y � CEMgNTMETHOD&3IvI0IINT
=
Im tion ft 20 ft. bentonite poured
0
Non-Water Supply Well: ft. ft
Recovery
Monitoring. ft
Snjection.Well: >f a'-cab re '• -.:;: ': •; :: :'
Aquifer Recharge Groundwater Remetliation �:S iND/G pA( CCpT y�pgOD
FROM TO MATERIAL
'Aquifer Storage and Recovvery 0salinity Barrier ft..
ft
Aquifer Test Dstormwater Drainage .•.•,..
Subsidence Control ft _ r---
t Experimental Technology :20.tiRILL1NG.DOG•(attach additiaiil s7?eewf recess"7". in slu;ett-): ;
Geothermal(Closed Loop) [ITracer FROM TO DESCRIPTION(color hardnw soWrocktype,gra
Geothermal(Heating/CoOling Return) Other(explain under#21 Remarks) ft ft
r ` 0 Y
4.Date WeIl(s)Comp ID
Completed: Well # µ ft. ft.
�
ft
Sa.Well Location: ft ft
Facility ID#(if applicable)
Facfii/ry/O�fw\nerName I ft
city,and Zip
-;`
Physical Address, ty, P r f/ �:216�xi ivtARTIR ;- .;i:.' :..•_ _
Parcel Identification No.(PIN) flit
County
5b.Latitude and long tude in degrees/minutes/seconds or decimal degrees: ration
(if'well field,one lat/``loug is sufficient) Q (�t� 2er �'-�--�
N so
• Sigma f rtified We}1 Connector',
Date
dance
6.Is(are)the wells) Permanent or Temporary B mining is form,I hereby certify that the wells)was(were)constructed In m�d a
�,{ x 15A C 02C.0100 or 15A NCAC 02C..0200 Arch Construction Standards
7.Ls this a repair to an e>dsting well: Dyes or ONO copy ofthis record has been provided to the well owner.
If this is a repan,fill out]mown weD constructton&iformafion and explain the nature of'he
repair under 421 remarla'section or on the back 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 Geoprob'e/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
1
construction,only 1 G W-1 is needed. Indicate TOTAL NUMBER of wells SIMMITTAL IN�HCT,IONS
drilled: s of completion of well
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit thus foam within 30 day' P
TJ
For multiple wells list all depths fdi;�erent(example-3 t@200'and 2Q100D construction to the following.
` QQ ({L) Division of Water Resources,Information
27699-163-7 nit,
f 10.Static water level below top of casing: 1617 Mail Service Center,Raleig ,
I Ifwaier level is above casing,use"+" the fo>m to the address in 24a
11.BorehoIe diameter: 6 (�•) 24b.For Injection Wells: In addition to sending
r above, also submit one copy of.this form within 30 days of completion of well
contraction to the following:
y 12.Well construction method: ection Control Program, -
p.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Ini 27699-1636
1636 Mail Service Center,Raleigh,
FOR WATER SUPPLY WELLS-ONLY. In addition to sending the form to
air pressure 24c.For Water SuoU1Y&Injection Wells:
i 13a.Yield(gpm) Method of test the address(es) 'above, also submit one copy of form
department art of thdays
county
k completion of well construction to the county
it Amount wee constnicted-
13b.Disinfection typ
iRevised 2 22 2016
i North Carolina Department of Environmental Quality-Division of water Resources
Form GW-1
i