GW1-2022-08525_Well Construction - GW1_20220907

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NC Well[^^bes±er CertificationNmnbet I5:OU�Eit�ASIIdG,fncmnlii asedwe�s)0 2L'I ¢ licahls'R::::•.• •`'
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Morgan Well &Pump, Inc. +1 ft ft 61181 in sdf11 pvc
Company Name j�, eotliermal closed-lob' '`: ''a' t:: -'
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2.Well Construction Permit#: ft ft
List aG applicable weII construc�on permits(te UIG Cowgv,State,Variance,etc)
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3.Wen Use(check wen use): r _.`_ r;•:..i•s .;x:'::.`•:-r• r::,:•...:
Water Supply Wen: FROM TO DrAMETER~ SLAT SLZB -TETCIQZABS 14IATFT27AL.
_Agncultural ElMunicipdIPublic ft ft.Geothermal(Heating/Cooling supply) Residential Water supply(single) ft - ft in
} Residential Wafer Suppl (shared)y '` .•.: h
I Commercial :`18.GROUT.•••..-. -...'•`�Tar�ttTaT• . . '��et�NTMETSOD g9MOUTcT
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gation ft 2D ft berrtotlfte. pow
DPPY
Non-Water 1 Well: O
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Monitoring nRecovery ft
Injection.WeII ft ft
_Aquifer Rechazge D Cuoundwater Remediation
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Aquifer Storage and RecoveryY
_Aquifer Test StonmwaterDrainage ft ft
Experimental Technology Oi Subsidence Control ft ft v,
Geothermal(Closed Loop) EITraeer :20.1DRILIINGSOG'(aitacliD ��ON�cao �oiUrock, `s grnm sia,etW `
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c Geothermal(Heating/CooDng Return) ri Other(explain under#21 Remarlm) n ft L ft
4.Date Wells)Completed: Well lD# 20 ft J ft
55 ft ft
52 WeII Location:
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Facility/owner Name Faclity ID#Cif applicable) � 7
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•Address,City.and Zip
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County Parcel IdeadficationNo.9Tq) 1 F�l C.' "' ('.
Infi;,�•�fg�ia,2
5b.Latitude and longitude in degrees/minutes/seconds or dedmal degrees: .%•° '^^ v
(ifwell fieldd,,one lat/long is Sufcient) ( ems J
S;�aed well Contractor Date6.Is(are)the well(s) Permanent or ��''Temporary that the'weR(s)was(were)constructed in accordancemiform,1 hereby ca�fy7.Is this a repair to an e�stingweIl: QYes or ONO wuhISM 02C.0100 or 15ANCAC 02C..020D F7eII Construction Standards and that a
If this is a repair,fiU out(mown weII construction idformadon and ezplain Ate nature of the copy ofAris record has been provided to the well auger.
repair under#21 remarla•section or on the back of this form 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 GeoprobdDPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. ludicafe TOTAL NUMBER'of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a For AD-Wells:
Submit this form widen 30 day5 of completion of well
For muktple wells Gat all depths#,&ffereni(,x=ple-3 OD'and 2Q100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
IfwatO level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 Crn•) 24b.For Iniection Wells: Im addition to sending the fog to the address in 24a
1, above,also submit one copy of this fo>m within 30 days of completion of well
12.Well construction method: _� construction to the following.
(Le.auger rotary,cable,direotpush,eta)
Division of Water Resources,Underground Injection Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;l2aIeir,h,NC 227699 1636
13a_Yield(gpm) Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the fora to
the address(es) 'above, also submit one'copy of this foam within 30 days of
13b.Disinfection typ Amonnt�� �Z completion of well construction to the county health department of the county
where constructed.
Revised 222 2016
Form Gw-I NDrtb Carolina Department ofEnviromneatal Quality-Division of WaterResources
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