GW1-2022-09710_Well Construction - GW1_20220907

1� 14:VITERZONES
Well Co ace FROM To DESCRIPTION r
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NC WellContractorCertificationNurnbet y;,O R,CggiHG,({apmultira�eawgns):ORLQ
Morgan Well&Pump, Inc. FROM TO DIAM]E ER 1 THI s
CSfi�'ES MAC
+1 tt 61/6k iL sdr2l pvc
Company Name " � :,,
J y 16.-ZqJ ER CAMN` OR•TUBLNU eotliermal cIo's d rod MATERIAL
2.Well Construction Permit4: ' f FROM TO DIAMETER fi r
1 T13ICHITR�S
Last all applicable well cowtructionpm7nits'(ae tnG Corativ,State,Variance,etc)' ft
ft in.
3.Well Use(check well use): ; ; , ..-_._`..;;.-r:•: ••:i
Water Supply Well: mom TO' - DIAMETER` SL.T SIZE THICKMS MATERIAL.
Agricultural E3Mmnicipal/Public ft ft in
t i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fL tr-
f rink J Residential Water Supply(shared)
fIni FROM TO ,MATERI+IL II�L4CE11I?NTMETSOD&AMO171iT
ter Supply Well: o ft 20 ft. bentonite• poured
ring Rvery ft.W tt ftr RechargeI Groundwater Remediafion GRAVELr Storage and Recovery DSalinityBamer FROM TO MATFRL,rr.Test 13Stormwater Drainageft ftental Technology Subsidence Control ft ft
rmal(Closed Loop) Tracer :ZO.2DRIIS�GLOG'(aitacli'sddidihc9FROM TO DESCRIPTION(ealor hardness,soil/roekt9pe, sae,etc)
nal(Heating/Cooliag Retum) J Other(explain under#21 Remarks) ft ft
b . �
4.Date Well(s)Completed Well ID# R' rt
a.Well Location: 25 h G
Facility/O Name Facility ID#I(if applicable) ft �
C D 1d r � u l P& ILd��� k1�Z8o tt ,4 p
ft. ft
P sical Address,City,and Zip
County Parcel Identincation No.(PIN) M z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1t1+vr "T �jqr�
(tfwell field,one lat&ng is sufficient) 2 er ration:
3�.532o N %0.5�4�2 W g 2Z
6.Is(are)the well(s) Permanent or Temporary
Sigma e f stifled Well Contractor Date
gnine is form,I hereby cv-gy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or *No wnle 15.9 C 02C.010D or 154 NCAC 02C•.OZ00 FPeII Conshuctian Sta»dards and that a
If this is a repair,fell out known we➢construction idformation and explain the nature of the copy of this record has been provided to the,Y ll Owner.
repair under#21 remarks section or on the bark of thisform 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'of wells construction details. You may also attach additional pages if necessary.
drilled: J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �v (fL) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deprhs ff d&•ent(arample-3Qa 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 27699-1617
11•BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
1-2.Well construction method: L` construction to the following.-
(Le.auger,rotary,cable,dsectpusl;eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
VrELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test air pressure 24c.For Water Supply.&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fbi m within 30 days of
13b.Disinfection typ Amount O Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources (� Revised 2 22 2016
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