GW1-2022-10714_Well Construction - GW1_20221209

Well Conn for ame �.
CASIlIG,(formniti-rasedwells)Q22ISI�RCrfa"]irahla)'J A':::•::''•
NC Well Contractor Certification Number 1'OQTER= :::: R , 7131 s6 MAC
FROM TO•
Morgan Well&Pump;Inc. F ft. ft 61181 i' sdt21 p"°
CASIIZG012•TIIBING. eoth.4m closed-lou'
Company Name qq �GGQQ �[Q' 16� DTAMF r EIL THICFQIEss MATS
V�...7�4 f�i FROM TO -
2.Well Construction Permit#: ft ft 1
List all applicable well constr•ucttonperinits'(r.e DIC,County,State,variance,etc)
R ft
3.Well Use(check well use): :M1a...;.`_ .;.:�.`.:: b• •r.::.::.
. 17.SCRF�EI`T'..:••.:c t •� D ,I, "- SOT SUE., TfilCid\'F�SS -ivIATERLS,.,•
Water Supply Well: FROM TO
� � in.
Agricultural M"I MunicipaliTublic
Residential Water Supply(single) ft ft in.
i Geothermal(Heating/Cooling SuPPly) .: :_ :.' ^'::'"•::%:
5 nd Commercial JResideufialWaterSupply(shared) ::18iGROUT::.• '1 T+
FROM TO � TMETS0 &91SouNr
Isi ation p ft 20 ft bentonite•�. poured
Non-Water Supply Well:
Recovery
Monitoring. ft ft �'
ft i,
-Injeetron Well �—,�
Aquifer Recharge E=tGrovndwatet Remedialion . if a"licable
:.79:S�LQD1GI21LVEI'PA-. **eTFurer. EY�LACEMFNTM�THOD
SalinityBamar FROM - TO
`Aquifer Storage and Recd'lleiy R ft
Aquifer Test 0stormwater Drainage
Experimental Technology Subsidence Control
ft ft
QlTracer :2B.tiRII�'GS OG'(attacli sddifionsl sheets�f aecess-col ins etc.)
i Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardness,soil/rock type grize )
Geothermal($eating/Cooliug Retum) I Other(ekplain under#21 Remarks) 0 ft Q ft d�
ft
4.Date Well(s)Completed: �t Z Well lD# a0s R
5 ft 35
Sa.We11 Location: -2L%:!, ft
�levc�r►b ft L ft.
Facility/OwnerName Facility ID#(ifapplicable)
` ft
t 1�Y Q.�__�tt ft -
aA
I' r
Physical Address,City.and Zip :•... ..
Y :Z16I1�;bL3RUR<'. •::>:. `�i: - :,4 -:.: ' . •'
Parcel IdentificationNo:(PIN) If1iv'i'iY?�.�'�;",l tom;-`?=•�`'-�:�
County I, I"i1­Oin(�'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(swell field,one laOong is sufficient) 5,wviab
cation:
8.9335.�1r�1�12 N 7 Date f rtified Well Contractor i6.Is(are)thewell(s) Perrmneut or rjTemporary thatthe well(s)was(were)constructed in accordance
ng isform,I herekv certify7.Is this a repair to an existing well' Xes or•�No I5.4 N C 02C.0100 or ISA NC 4C'02C:0200 FPeA Consh action Standards and that a
Iftlus is a repan,fll out!mown well consb action iriform�ion and explain the nature of the
copy ofthis retard has been provided So the well aw�ier.
repair under 4111 remarks section or on the back of this form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprob'e/DPT or Closed-Loop Geothermal Wells having the same construction details. you may alsi;attach additional pages if necessary.
construction,only 1 GW--1 is needed. Indicate TOTAL NUIVIBER'of wells SUBMITTAL INSTRUCTIONSI'
drilled: I;
9:Total well depth below land surface: 1 (ft) Z4a,For All Wells: Submit this form within 30 days of completion of well
ths ifdi•fJerent(example-3@200'and 1@100-) construction to the following i
For multiple wells list all dep
10.Static water level below top of casing: �b (ft) Division of Water Resources,information Processing Unit,
Ifwater level is above casino use"+"
1617 Mail Service Center,Raleigh,NC 27699-161-7
(in. 24b.For Iniection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: 6 ( )
_ �•� above,also submit copy of t1uS form within 30 days of completion of well
11 Well construction method: construction to the following: !.
(Le.auger,rotary,cable,dircetpush,etc.) .
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
Zo Method of test
art'pressure 24c.For Water SuuUly&injection Wells: In addition to sending the form to
13a.yield(gpm) the addresses) 'above, also submit one copy of this fowl within 30 days o
Amount completion'of well construction to the county health department of the county
13b.Disinfection typ where constructed.
e
Revised 2-22 2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1
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