GW1-2022-08588_Well Construction - GW1_20220906

•Ia:.wA.TERzor�s;. ... .
FROM TO .DESCRIPTION -
well Ccjraq&amc ft
fL
1.
' �� r R ft.
NC well Contractor Certification Number yi;ODL�ASING,(for mnlh casea wells)
Morgan Well &Pump, Inc. FROM TO' DW�4ETER T�rms�ss hUTERIAL
+1 ft O R 6118/ sdr2l P c
Company Name
i FROM 1ER CA.4NG OE•TI1B G: 'eotfiermal-cla'CMgES
2.Well Cons1ructionPermit*: 1 132�3 FROM TO DT"^� T�cl ss MaTERrAL _
R R
List all applicable well constructionpermits'(i e.EUC,Coutztr,State,Vark=4 etc)-
3.Well Use(check well use): R ..-• + - - -
17:SCREI�r'.::: _ •. . .:. .;t. .
Water Supply Well: -. . '._• ._:.SLOT
•:�=',::,t.-•:...,•.
PP y FROM TO' DIAMETER SLOT SIZE TATCiQZBSS MATERIAL
Agticultural D`t MunicipWPublic R ft in
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft fL in.
I Commercial J Residential Water Supply(shared) ,.:.:.•::-__.:. :r::'.;,;r^;- -r
: RO
Irrigation FROM TO :' :MATEItTA1 _ FZ>�I ACEMENT MF THOD&9MOIINT
JN�nter Supply Well: o R 20 ft bentonite- Poured
oring Recovery R ft
n WeII ft ft
r Recharge (Cnroundwater Remediatioar Storage and Recovery DSalinityBarrier FROM Tor Test DStommwater Drainage fi ft'
mental TwInolov �J Subsidence Control R fL
rmal(Closed Loop) Tracer :20.DRD�INGLOG'C onsI sheets ti ae 7:'_�; gr= et)FROM TO DESCRIPTION(color,hardness,solumck e, n sire,err:)rmal(Heating/Cooling Retum) J Other(explain under#21 Remarks) _ _ ft
4.Date Wei1(s)Completed: well m# 35
SR.Well Location:
3S � O R
r ka.'�Y.r'SQy� R ft. _ 22
Facility/Owner Name Facility ID#Cif applicable) ft. r2
nI- _ ftft ark tkllliviiaj sti^l V f ^.S;r:,.<:2=J 1)ri;
R ft
P sical Address,City,and Zip
�'K, r� -21;�17M6RR'R".•.-c':'_::-:
County ParcelIdentificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(n well field,one lat/long is suftcient) j155A
ration:
3S.a-Sq4 'N V%J 0 � W 12 2-
alk
6.Is(are)the well(s) Permanent or Temporary
ed Well Contractor
D
isform,I herebv certify that the wa(s)was(were)constructed in accordance7.Is this a repair to an existing well: OI Yes or f No C 01C.010D or 15A NCAC OZC•.0200 WeII Construction Standards and that a
If this is a repair,f;A out)mown weD construrtfon biformation and esplain the nature of the copy oftW record has been provided to the well memer.
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER*of wells
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths#,,ffj Brent(exmnp!-�30,11 and 2@100) construction to the following.
10.Static water level below top of easing: (ft) Division of Water Resources,Information Processing Unit,
Ifwata level is above casino use"+" 16I7 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition ito sending the form to the address in 24a
above,also submit one copy of this foam within 30 days of completion of well
12.Well construction method: IT� L� construction to the following.
(i.e.auger,rotary,cable,directpusb,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
132.Yield(gpm) Method of test: air pressure 24c.For Water Suppl-y&Iniection 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 t5P Amount: 15OZ completion of well construction to the(county health department of the county
where constructed.
Revised 2 TZ 2016
Form Gw-1 North Carolina Department of Environmental Quality-Division of water Resources �f
I