GW1-2022-10212_Well Construction - GW1_20221111

I WelRC_-z;q&_ mom TO I DESCvrv"1"tutu
I ft. f,
� , -Aft ft
NE-Well Contractor Certification Numbet
)O—RLIKM rff1Bblimi.�k;.!-"
Morgan Well &Pump, Inc. FROM I To. I ino nV TWrjR DIAACETFR I Ta[Clairss -MATERIAL
Company Name
+1 140 ft.ft. 6 1/a/ sdt21 pvc
I
I JrDUUR CLqNG 09 =�.TUBtW"
2.Well Construction Permit#: FROM TO THICK?ZESS MATERIAL,'
fL
List all applicable weR construction Permits'rL a DID tarty,State Variance,etr_f
3.Well Use(check well use): & !L
Water Supply Well:
Or TO DIMETER SLOT SIZE T1170MMS MATERIAL-
Agricultural E DMUnicipaypublc
ft. ft. ft
Geothermal(Heating/Cooling Supply) jpResidential Water Supply(single) ft ft.
Commercial Residential Water Supply(shared) GROUT-."'-
lai 'on AMOUNT
FROM TO I MAxEPJAL i 11 EMPLA
Non-Water Supply Well: ft 20 ft bent'Dnitg. poured
Monitoring
DRecovery, ft ft.
-Injection Well. ft ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery !`I Salinity FROM TO MATERIAL Y=OD I
n
-Injection.a'
Recovery
Aquifer 7d on,
Groundwater
-1-ti
Bawer
ter Drainage
St
eu..C
fAq
Aquifer Test 0stormwaterDrainage ft
2
_j Experimental Technology E3Subsidence Control f, ft
Geothermal
1 Ge-othexmal(Closed Loop) 13Tracer
Other
I FROM TO I DESCRIPTION(color,hardness,soiyrocktypp�zx-ain sim,etc Geothermal(Heating "am
/Co.lingR. r D IR t'i jjOthr­(.,Jinrmde,,#2_ ft ft.
i i.*-I- . A,i- - RF
4.Date Well(s)Completed W-11 m# 144 "t- -
Sa.Well Location: 41 f, 1 UIA- C ED
lsw'� :�&�S 1 (60 R. l3v ftxN
Facility/Owner Name Facility M*(ifapplicable) ft fL 9AA&—f—L Infor
ft ft. DAIQ/ uno
Z21(!S.
Physical Address,_City,;mAip ft. ft
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ffwell field,one lat/lon.-is sufficient) 2 Cation-
3S.Srns 'N W Cz;72;;? 9 1 ZA 2-2-
6.Is(are)the well(s)*Permanent or [2Temporary Sigmae ed Well Contractor Datk
is form,I hereby cerf#y that the wen(s)was(were)constructed in accordance
v0l -�TCO2C.0100
7.Is this a repair to an existing-welh DYes or ®No a'15.4 JVC,4C 02C..o2oo Fw Construction Standards and that a
15A
If this is a rep
air, our known wel7construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the bark 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 017 well
construction,only I GW-1 is needed. Indicate TOTAL NUMBERof wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3tJ (fL) 24a. For All Wells: Submit this fbim, within 30 days of completion of well
For multiole'weRs&I all depths irdIfferent(ammnple-3@20D'and 2@100) construction to the following
10.Static water level below top of casing: Unit
(ft) Division of Water Resources,Information Processing
fwater level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6
(in.) 24b.For Infection Wells: In addition to Sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: LI construction to the following:
(Le.auger,rotary,cable,directpush6 eta)
Division of Water Resources,Undergr6 und Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
pro) 24c.For Water Supr'
13a.Yield i(gpm) Method of test: air pressure IV&Injection Wells: In addition to sending the fban to
Y the address(es) 'above, also submit one copy of this fonn within 30 days of
_ft completion of well construction to the county health department of the county
13b.Disinfection typnft Amount. 17,
where constructed
Form GW_l North Carolina Department ofEnvironmental Quality-Division ofWaterReso=es Revisrd2222016