GW1-2022-09272_Well Construction - GW1_20221003

2wen uomrarZvame i`0 `Kv t o&& !
l 1'fili -A ;_JJ IL R i
NC Well Contractor Certification Numbet 15:OUTGR:CASING,(fo"r mnlfl=cased w ErBs QR
Morgan Well &Pump, Inc. FROM TO• DIAnMTER i Tmt ss M1:T> �
+1 fl ft.
sdr21 IV-
Company Name y
2 4 J` 16 IITER� OI2•T(JBII�G. 'eotfiermal closed lori'
2.Well Construction Permit#: 2 .. FROM TO DIAMETER t THICENESS MAI L
List all applicable well construction permits'(Le U1C,Cowgv,State,Vir once,etc)• fL ft in.
3.Well Use(check well use): ft ft i3L _ _ - .yr•:-_
17_-SCREEN'._:.:'''.'- `•:.r'•.:•`- _:r{•:•;::.•:
Water Supply Well: FROM TO DW4ETEA~ SLOT SIZE TSTCKNESS I MATERIAL.
Agricultural CIMunicipal/Public ft ffi in.
Geothermal(Beating/Cooling Supply) ®!Residential Water Supply(single) ft
I Td Commercial !Residential Water Supply(shared) r •-•%..::" ,::; _;:-;` z z'-'• _`` ;
— ::18:GROUT•::•... :, =':' ;-::--:�. •.." -
i 13i ation FROM TO i MATERIAL '.. EMPL-ACEMENTMETHOD&9M0'ONT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft.
Snjection.WeII:
ft. ft
Aquifer Cn Recharge oundwater Remediation ;
79:SAND/GRAVEL•PA CK
Aquifer Storage and Recovery DSalinityBamer FROM TO - MATERIAL EiYPLACEMENTMETHOD
_Aquifer Test StormwaterDrainage ft ft'
1 Experimental Technology OSubsidence Control ft
iGeothermal(Closed Loop) Tracer :20.DILLIN RGM0G'0-ttarli dditionsIsheetsifnecess"7'='
FROM To DESCRIP ON(molar,hardness,soi]/rnck type gram size ete)
Geothemal(Beating/Cooling Return) 0 Other(explain under#21 Remarks) b ft TI�
4.Date Well(s)Completed: 22 Well ID# ft it
52.Well Location: b 1
ft ft
Facility/ erName6 u&10 Facility ID#(ifapplicable) ft ft _.
3 K Zg�a. ft a. „ .6
P iiccaall A
�ddr
rees
s
,City,and Z• ft ft 0 ,
�de►Yf.d ■VS `21EBF.MARTCC`� _ _ '7. _ _ '•r`:.-�:.::` �c s-. .r✓ .
County Parcel Identification No.(PIN) �(►i sir F r^
5b.Latitude and longitude in decrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 ration:
3S.35(Q► N �b W 2�
6.Is(are)the well(s) Permanent or Q!Temporary Sign e f rtified Well Contractor Date
B gnfno is form,I hereby cer4,fy that the well was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ®No wuh 15A C 02C.0100 or 15.4 NCAC 02C 0200 p7ey construction Standards and that a
If this is a repair,ffl out(mown well construction Ldformadon and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#11 remarks 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 I GW--1 is needed. Indicate TOTAL NUMBER*of wells construction details. You may also attach additional pates if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form:within 30 days of completion of well
For multiple we&list all depths if different(example(,3@,200'and 2Qa 100) constivction to the following:
10•Static water level below top of casing: 1 O (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: 1n addition to sending the fame to the address in 24a
f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: c dl �LN construction to the following.
(Le.auger,rotary,cable,directpush,etc.)
' 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
13a.Yield(gpm) J O Method of test: air pressure 24c.For Water Suunly&Infection We Lis: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: 45 completion of well construction to the county health department of the county
where constructed-
Revised 2 22 2016
Form GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources
!
I
i