GW1-2022-08497_Well Construction - GW1_20220907

1 r���w •14:,.V TERZONES
FROM TO •DESCRIPTLON•.. .
Well Co for Lae R ft-
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NC Well Contractor Certification Number 15;pp�ERCdSING.(formnl&dasedwells)b12 mom
Morgan Well &Pump, Inc. FROM TO' DL4METER THIc agEss MATERLLL
+1 R R 61/8/ �, sdr21 pvc
Company Name 16"IIRdER GOR•TUBING, eotliermalrlo'sbd�od`
2.Well Construction Permit#:
�a3�L FROM TO DIADti3TEft TSICmmss rvraTERrnr.'
List a➢applicable we➢construction permits(Le UIC,Cowrh State Yariance,etc)' ft R
3.Well Use(check well use): ft R � '
I7."SCRIM''.=:.: ._ •. . •... .ti;.
I
ater Supply Well: >;ROX TO' DIAMETER~ 1 SLOT SIZE ^THrCKN&SS r�IATERIAL.
Agricultural 13Municipal/Public ft ft in
Geothermal(Eeating/Cooling Supply) Residential Water Supply(single) R
ercial J Residential Water Supply(shared)
P ;:'18:GROUT'::••.•_, =':` :':•°":• •"
fN
'on FROM TO MATERUL MUL4CHMENTMETHOD&AMOUNT
ter Supply Well: o R 20 R bentonfte• Poworing Recovery R ftn.W-eII: R fL
rRecharge QI Groundwatea Remediaiion �:SAID/GRAVEL P�CK rf a"licablb r Storage and Recovery �(Salinity Bawer FROM TO MATERIALr Test oStoffiwater Drainage t. Rmental Technology O!Subsidence Control R Rrmal(Closed Loop) Tracer :M.DRUMNGLOG'' cli-R3di>iGusIshetsjt'aecess- t:FROM TO DES PTION(color,hardness,solurocktppe, sze,rmal(Heating/Cooling Return) Other(explain under#21 Remarks) Q R ft
4.Date Well(s)Completed: Well M4 5 R n_ r
52.Well Location: R It.
• ��� Srn�� �D ft. R •
Facrlity/Owner Name Facility ID#(ifapplicable). 5 R
2ko Salltsbvey NC 2!44 R R
J.bziral Address,City,and Zip ft fL — � .PM
4,17 413
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County ParcelIdentificationNo.(PIN)
5b.Latitude and longitude ill degrees/minutes/seconds or decimal degrees: „tg r"
(sfwell field,one lat/long is sufficient) CZ;72:;?
r 4C�Pic
q 1 0 � i 345.�6 l� N� c� 11 W
6.Is(are)the well(s)Vermanent or OTemporary 7M.5175.4
rtifiedWeflContractor Date
g is farm,Ihereby cr�tifythat the we➢(J was(were)constructed in accordance
7.Is this a repair to an existing well: [ Yes or fNo C 02C.OI00 or 1.5A NCAC 02C..0200 lYe➢ConSftVCdDn ptandmds and than a
If this is a repair,fill out(mown we➢construction information and explain the nature of the copy ofthis record has been provided to the well aw�rer.
repair under 421 remarks section or on the back ofLhisform 23•Site diagram or additional well details:
8.For Geo robe/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 TOTALNUNIBERofweils construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2D (fL) 24a- For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths if dif ferent(ermnple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: !4 p (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 16I7 Mail Service Center,Raleigh,NC 27699-1617
11,BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the fomm to the address in 24a
( above,also submit one copy of this foam within 30 days of completion of well
12.Well construction method: L` construction to the following. •
(Le auger,rotary,cable,direct push,etc.)
• Division of Water Resources,Undergrannd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 O Method of test: air pressure 24c.For Water Suuuiv&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this four wi`drin 30 days of
13b.Disinfection typ Amount: �OZ completion Of well construction to the county health department of the county
where constrabted.
Revised2 Z2 2016
Farm GW-1 Nortb CarolinaDepsrtment ofEnvironmcntal Quality-Division of Water Resources
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