GW1-2022-10824_Well Construction - GW1_20221209

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DESCRIPTION
Well Co FROM TOrrntracto Name ft ft •
ft ft
NC Well Contractor Certification Number
� 'I5:OUTT•R:G�ASIIQG,(fnc mnlii=rasedwells)ORL•'II�+2 Crf'a'licahle)'-,:�::'.::•'.
Morgan Well &Pump, Inc. : FROM TO' I DIAMETER xFacr Ess ISATMWL
+1 ft• ft. fi 1/Sl in sdr221 pvc
2.Well Construction Permit
Company Name
16'Il�trvEIt CASW 012•TUBING:''entliertnal•cIb'sed-ltid`?,,:.:'.._' ::%:...-.�. .
"r: /c-� FR OM TO I DIAMETER THICENESS MATERIAL
Zfst all applicable well construction permits'(ie.UIC,County,State,Ya:aance,etc_). M'
3.Well Use(check well use): ft ml
A—!
ater Supply Well: 17.SST',
FROM TO DL4METER +SLOTS THICKNESS MATERIAL.
Agricultural JM'Municipal/Public ft ft in.
Geothermal(Re-ating/pocEngSupply) Mi ResidentilWteSupplyLsingle) ft in.
TndustriaUCommercial' J Residential Water Su 1 share -
18rGROSTT
:'Imaatiou FROM TO MATERIAL! Eraj&CEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft bentonite• , poured
'•Monitoring Recovery ft ft.
Injection Well: ft ft
_,Aquifer Recharge Kt Groundwater Remediation _
79:SIIdD/Q2A-VEL'PACK if a'•likable -::_'':;'',".:'.'=,•':.'
Aquifer Storage and Recovery Salinity Bawer FROM TO MATERIAL X PLACEME D0MOD
J Aquifer Test []StormwaterDrainage ft ft
i Experimental Technology oSubsidence Control fL ft,
i Geothermal(Closed Loop) [ITracer :20.DAT,"II'i RG.LoG'(attacii dditidnaZ sheets if recess 7i� ):'.
I Geothermal(HeatinglCoolingRetirn) J Other(explain under 021 Remarks) FROM TO DESCRIPTION(color,hardaes,saillrock ty a grain sae etr)
L �j-
4.Date Well(s)Completed: ?,?-Well ID# 0• ft i9_2 it /(pw^ '
52"Well Loc2tion: 50 ft
e o I ft On �cr� • �
Fac 'ty/Owner Name Facility ID#(if applicable) -
&Iola Ole IT •/^� ft ft
Physical Address,City,and
ddfZip ft ft I F C 4
C'7GtsZ�i r ZL'RFareRuc' - --_ '.: =-_•,d.:::'_.:_t,.:':.•:::::
in oir7: ;inn
County ParcelIdentincationNo.(PIN) ,.. -
c3;
5b.Latitude and loan tude in degrees/minutes/seconds or decimal degrees:
(iffwwell field,one lattlong is sufficient) J 22.Cerlifira'on
6.Is(are)theweIl(s) Permanent or �ITemporary S fCertifiedWellContractor Date
eo
By signing this form,1 hereby cert*that the wells)was(were)constructed in accordance
7.Is this a repair to an existingwell.• MYes or fiNo with 15ANCAC 02C.0100 or 15,4 NCAC 02C;.0200 P7.H Construction Standards and that a
If this is a repan•,fill ouf blown well construction Ldformation and explain the naiw-e ofthe copy ofthis record has been provided to the well owner.
repair under 421 remark 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 NUMBERbfwells construction details. You may also attach!additionalpages ifnecessary.
drilled. 9 SMMPTTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a.For All We11s: Submit this foim.within 30 days of completion of well
For multiple wells lisf all depths ff df�ereat(example-3(200'mud 2@-100) eonstmction to the following.
10.Static water level beIow top of casing: (ft.) Division of Water Resources,Information Processing Unit, -
Ifwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) C 24b.For Iniection Well*: Th addition to sending the foml to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0:0�q construction to the following.
(Le,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS,<JNLY- 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water 5uunly&Infection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: "Or';14e Amount: 1 � 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 • i Revised2 22 2016