GW1-2022-08548_Well Construction - GW1_20220906

/p` •14:,wATERZONES•;', •r.
.� �"'' FROM TO .DESCRIPTION
Well Co for time h ft ft
` ft ft.
NC well Contractor Certification Nmnber
'` '13:OU7'ER raseiiSveIls)bRL' 'II�ERCrf 'lirzhIe}'-'s:�::'.::•••
Morgan Well&Pump, r Inc. FROM TO' DTdM ZER Tarc}S�lz nxsz>
+1 ft 61/61 m' sdr21 pvc
Company Name "<••;
�^ �i1 1$;ZI rII�.QZ GOE•')'tIBI1�G:' eotliermslclo'sed3oo'
2.Well Construction Permit4: FROM TO DTdnn�'rFR THICHI`IESS .~n2A-TERIAL
Zist all applicable WRY consiruationpermfts'(Le.UIC,CoW4,State,Fo iance,etc)' ft R' in.
3.well Use(check well use): ft
Water Sn I weII: 17_SCREEI4'„ _:. .' :'•._• _.,::: r:;,.:�,::.:•:.r,. . 1vIATEIA'
PP Y FROM TO' DIAMETER SI OT SIZE THICICNI:SS A1'RIAI,
+Agrioultural �M'nnicipal/Public fc � �-
5 ?Geothermal(Heating/Cooling Supply) �Resldenizal Water SnPP1Y(s�F�e) _ ft fr. �-
I lnduslriaUCommercial I Residential Water Supply(shaa'ed) ,:7s:GROUT..:,-•_ _" '::-.::•'•"Y'�.�,-�."- ..��`)::. -^:'- -?''`:,�.`�-•�•-`';.
!Ini OIl FROM TO MATERIAL EMPL4CEMENTME7�OD&AMOIMT
Non--Water Supply Well: D 20 bentonite- poured
Monitoring f3Recovery
-Tnj ection•Well:
& ft
!Aquifer Recharge I GroundwaterRemediation r.:•:
— ;19:Cr
zf a"licalile '
Aquifer Storage and Recovery DSalinityBamer FROM To Me FRrdL EMPLArF�^FNTrIti 01)
Aquifer Test DStormwater Drainage ft ft
I Experimental Technology Subsidence Control ft
Geothermal(Clos ed Loop) DTracer :2D.?)RILLaiGIOG'(attach'zidziittousls&Ztsitaeces
Geothermal(Heating/CooliagR-tum) J Other(explain under#21 Remarks)
FROM To DESCRIPTION(colo,hardness,soiltrocktype aainsae ett)
a..Date Well(s)Completed:v ? ZZ Well M# ft-] ft
Ea.Well Location: ft 3 ft 1
ft ft
Facility/Owner Name Facility 3D#(if applicable) ft. rt'
5 Cm wclJ<x_, r.1'4 or, czhcmi hc Z ft. 5 F
P/��srcalAddress,City,and Zip ft ft -r•i [irY1
(..lJt►�CA.,YYV S �il:-ufirnraRuc, - - - __ t+„�` - �v;-_'' .___- -
county Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(swell field one]at/long is sutincieni) 2 ration'
35.�1gs3 N -Sq. 727I w 2-5 2Z
6.Is(are)the weU(s) Permanent or OTemporary _SigoabK bf Cjgrtffied well Contractor Da e
B o zing is form,I hereby certify that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0+Yes or #No "im 1514 C 02C•0100 or 1SA NCAC 01C•.0200 WeR Const-uction Standards and that a
If this is a repair,fzR out Imown, construction information and erplmrz the natut e of the copy of this record has been provided 1a 1he well owner.
repair under 421 remarks section or an the back ofilzis 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 NUMBER'ofwells construction details. You may also attach additional pagesif necessary.
drilled: h SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/C) (fL) 24a. For All Wells.• Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii#krew(example-3@200'and 2@100) construction to the following.
10•Static water level below top of casing. �� (ft) Division of Water Resources,Information Processing Unit, -
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells-- In addition to sending the foffi to the address in 24a
[ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,dnectpusk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 v Method of test air pressure 24c.For Water Supply&fniection Wells: In addition to sending the form to
n the address(es) 'above, also submit one copy of this foffi within 3D days of
13b.Disinfection typ Amount [.[)7_ completion of well construction to the county health department of the county
where constructed.
Revised 2 22 2016
Form Gw-I North Carolina Department of Environmental Quality-Division of water Resources