GW1-2022-10167_Well Construction - GW1_20221110

I.W ontractor Inf matron:
-14:.WATER ZONES
Well Con or ame FROM TO DESCRIPTION
it ft
- ? , —� NOV 1 0 2022 ft. ft
NC Well Contractor Ce caon Number
� ti � 'I5:OU7'ER:12AS1NG.(foc mnl5-6sed•wells ORI:�-+R CrFa livable,�:�::'.�.;:•-.
Morgan Well&Pump,Inc. ingon►+ cn Pr. Unfit :I FROM Io' nlAnsETER THICIMaN 8s MATERUL
+1 ft it
t fi sdr21 pvc
Company Name 1d C45 01t•T[7BING.' en'tliermalclo'sed-too
2.Well Construction Permit#: N JA FROM TO DIAMETZ R THICKIQESS MATERIAL'
List all applicable well canstrrictionpermits Le.Wr,Comriv,Slate,Ymirarce,etcr ft ft. in.
3.Well Use(check weII use): ft in.
Water Supply WeIl: FROM TO DIAMET$R SLOT SIZE TffrCKMS MATERIAL.
Agricultural CDMuaicipabTublic ft it. in.
b I Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. fL in.
17n3usiri ommercial J Residential Water SuPP1Y(shared) ;Ye:t:ROVT:t• -.:: ::::.':'=`' :`::'' `: :': ':`- - `+`: -`
fN
liFROM TO MATFRTdT. EMP CEMENT METHOD&AMOUNT
ater Supply Well: o ft 20 fL bentonite oring Recovery ft. ftn-Well. ft fter Recharge Groundwater Remediation
r Storage andRecd�ery OSaliityBanier FROM TOErlti?LACEMFI1Ti1SETHOD
r Test DStormwater Drainage R'mental TecbnolmW �NSubsidence Control ft ftrmal(ClosedLoop) Tracer :2B.tiRIL1,�TGIOG attadisdditi6iiilslieed fnecesFROM TO DESCRIPTION(color,hardness,soiUrock type,gramsize,etcrmal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 It 10
ft
4.Date Well(s)Completed: 0 3117,Well ID#1 16 ft 2n ft-
5a.Well Location: ft �
C�rwc�k_�cax� �ev� 5 ft 6
Facility/Owner Name ` Facility ID#(ifapphcable) it. ft
Physical Address,City,and Zip
County Parcel Identification No.(PIIq)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
�(>fwell field,one]at/long is sufficient) �r.� 2 cation:
N 11V
6.Is(are)the well(s) Permanent or OTemporary Signs e f led Well Contractor Date
B e vno is form,I hea•ebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing weIL Yes or ffiNo wuh ISA C 01C-01 DO or ISA NCAC 01C.0100 FPeII Consnuction SYandmdr and that a
Ifthis is a repair,f�out/mown weII consb uction Mformation and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back ofihisform. 23.Site diagram OY additional well details
8.For Geo robe/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: 'lDb UL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiole'wells Ilat all depths ifdifferent(exam-3@2//000'�'and 1(e 100D construction to the following.
10.Static water level below top of casing: 3V (ft) Division Of Water Resources,Information Processing Unit
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the foffi 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: L6 construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VvTZJ S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L 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 form within 30 days of
13b.Disinfection typ Amount- completion of well construction to the!county health department of the county
where constructed.
Revised 2-22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources `