GW1-2022-10243_Well Construction - GW1_20221111

I FROM I TO DZSC?=011
well Co tar are I &
-A ft. ft.
NEWcii Contractor Certification Numbet 15;0UTM.QAKVGffdi CLR
Morgan Well &Pump, Inc. d FROM I TQ*
Company Name +1 ft. ft 6 11W sdr21 pvc
I -MOM ALATERIAL'
2.'WeU Construction Permit#: lb o_ AL 71.?A 1 FROM 1 TO I MGM= t TZIC32-mss
List all applicable wafl construction pa=its'rE e.7!11Cy Coup ft ft i
z7,'SAof4 Vzv-&,'ce�etc,� r L
1
3.Well Use(check well use): & ft in
V Water Supply Well: FROM TO I DLUyrZT7R I SLOT SM THTCKMS MATMERWAL t Agricultural 0MUniCipaL/Public ft. in.
Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft JJL
Co�P*r atDiResidential Water Supply(shared) '18'-GRO
b itrigation FROM TO Zry2LACEI1II�. l=' OD'&AMOUNT
]Non-Water Supply Well: 0 ft 20 fL bet'Dnit.. poured
DMonitoring mp..Vy ft ft
Jljection- ft ft
Mquif-Recharge Groundwater Remediation
Aquifer Storage and Recovery DSeinfiyBarrier TO 3hffLACMMNT AMT9QD
& ft.
Aquifer Test OStormwaterDrainage
I Experimental Technology DSubsidence Control ' I ft
Geothermal(Closed Loop) 13Tra= j:2B.'DR]11MG.L0�(�iV�dditiail s
I DESCRIPTION(color,hardness,soHftrktype�gr=si=6 efr-)
benlmi'a
FROM To
i:'Ucbl-.
ft_
I
Geothermal(Healing/Cooling Return) rilOther(explain under#21 Remarks)
ft. ft,
I YtA
4-Date Well(s)Completed: ZA j 22,Well JD# ft ft
20. ft. A ft-
Sa.Well Location: 4S
ft. ft
VM
ft f L
Facility/Owner Name Facility]D#(If applicable)
1OL13?0law. ft. ftRX
ft
Physical Address,City,and Zip f,
zuzz
county ParcelldentificalionNo.gVq)
lnforwwb:i�.)n Pr..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - - - . _,M- .I•
(1fWQ field,one lat/long is suf�cient) cation, DWOMOG
N
Sign f i ed Well Contractor Date
6.Is(are)the well(s)Verrngneirt or [3T—porary
B o vng is form,I hereby cw#51 than the wefl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []yes or *NO 15.4 C 02C.0100 or J5A NCAC 02C..0200 F70 Construction Syandkrds and that a
.0'this is a repair,,ftV OUI k7DWI weZ construct on ififormation and oplain the nature of the copy ofihjs record has been provided to the well aunzer.
repair under 421 renuzrla section or on the back-Df this form • 23.ScIte diagram or additional well details:
S.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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additionalpages ifnecessaxy.
drilled:- SMIVHTTAL INSTRIICTIONS
9.Total well depth below land surface:.45co (ft) 24a.For All We,lls: Submit this lbim within 30 day§ of completion of well
For muldple'wells&I all depths br&ffPr&nt(==.p&-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: q15 (ft.) Division of Water Resources,Information Processing Unit
fwater level is above casino use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: f-0W above,also submit one copy of this form within 30 days of completion of well
constriction to the following.
(Le-auger,rotary,cable,directpusk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SDPPL VVFff-LS ONLY: 1636 Mail Service Center,Raldgh,NC 2 7699-1 63 6
13a.Yield in) c)-/Z Method of test air pressure 24c.For Water Suppiv&Injection Wells:�In addition to sending the f6im to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typer)A Amount: completion of well construction to the county health department of the county
where constructed.
Form Gw-I North Caroliaa Department ofEnvironmental Quality-Division of water Resources' Revised 2-22-2016