GW1-2022-10732_Well Construction - GW1_20221208

wx,1j,uuiNb'1"1-tUC'110 N RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
10 a •14:.�ATERZONES:'. - :::
C Cl a a FROM TO DESCRIPTION r
Well Contract Name ft ft f
C4666 - A ft.
NC Well Contractor Certification Number I5:OU�ER:CAS]A'G,(foc ra fi-rased wells)0WE;IIlEZt if' 7irable)'1:::;.:: '•
Morgan Well &Pump, Inc. FROM ro' DIAMETER Tr�cI�TEss MATERIAL
+1 ft• ft 61181 n. sd21 pvc
Company Name 16-INNER CA BONG OR•TIJBING.- eotheim2a closed-lad"
2.Well Construction Permit#: 1 (T�IJ LZ r y V� (� FROM T DreMFrFit THICffiTESS MATERIAL
O
List all applicable well constr•ucSon permrds'(Le LUC,CounN,State,Ym iance,etc_)• ft' ft in.
ft ft in.
3.Well Use(check well use):
Water Supply Well:1 17_-SCREEN',�•:.�;.�`:,-. .�•...'•.:•�;.::=.�:�:_�:.•�•�='.::.;::•�::`i;•:;r.'�:;-...:::••' .•:
FROM TO DIAMETER SLOT SIZE THTCKNESS MATERIAL.
i Agricultural MunicipalNublic ft ft
1 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
ushiaUCommercial i Residential Water Supply(shared)
•.Irri ation FROM TO MATERIAL EMPLACEMENTMETHOD&?MOUNT
Non-Water Supply Well: 0 20 ft' bentonite• poured
Monitoring Recovery ft, ft.
Injection Well: ft ft
Aquifer Recharge �GroundwaterRemediation = '••
�, ;.79:SAND/GRA VEL'PAM rt a
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL MP1 AuME iv=OD
—I Aquifer TestIStormwater Drainage ft ft
1 Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) �ITracer :28.DRIISMIG.DOG'(attaclisdditidn'al sleed.if i ecess"-j'' i'r. :_ .'
FROM TO DESCRIPTION(calo,hardness;soiUro. type,grain size,etc)
{ i Geothermal(Heating/Cooling Return) 1 Other(explain under#21 Remarks) ft 6n ft
4.Date Well(s)Completed: ZZ Well ID# fc ft , M
Sa.Well Location: Vft. ft // Ra'G k.
ft
Facility/Owner ee pn Facility ID#(ifapplicable) ft
QI d( oL(AX te..d ift ft.
Physical Address,City,and Zip ft ft
County Parcel Identification No:(PIN)
Sb.Latitude and long trade in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) —wel� 22.Cer on:
- Z4J z -N
6.Is(are)the well(s) 'ermanent or QiTemporary
Sign a of C.ertifiedAWell Contractor Date
By signing this form,172erebv cerfrYY that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I Yes or I No with 15A NCAC 02C.0100 or 1SA NCAC 02C..0200 YYell Const uctton Standmds and that a
lfthis is a repair f:ll out]mown well construction information and explain the nature ofthe copy ofthis record has beenprovided to the well owner.
repair under,#21 rinnarla•section or on the backof 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUNIBER of wells
drilled: • - I SUBMITTAL INSTRUCTIONS-
9.Total`well depth,below Iand surface: /SS (ft-) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths 1fdIerent(example-3@200'and 2@100) construction to the following.
10.Static water level beIow top of casing: (ft.) Division of Water Resources,Information Processing Unit,
.lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wens: In addition to sending the form td the address in 24
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 0 n�L construction to the following:
(Le.auger,rotary,cable,direct push,etc.) J '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSFONLY: 1636 Mail Service Center,Raleigh;NC 27699-1 63 6
13a Yield(gpm) Method of test
air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
�7 7 the address(es) 'above, also submitione copy of this form within 30 days of
13b.Disinfection type e?/•�'1 Amount: l C� completion of well construction to the:county health department of the county
where constructed_
Revised2 22 2016
Form GW-1 .E1; North Carolina Department ofEnvironmental Quality-Division of WaterResources �•
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