GW1-2022-10823_Well Construction - GW1_20221209

vV VC&i OM TO DESCRIPTION
Well Contractor are ft
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'15 F Iunlfi=cried wells)O_R CSe)t�RTA' L:'
NC Well Contractor CertificationNumbet OOUXE-R, TO'
FROM ' DIAMETER
Morgan Well &Pump, Inc. ft. ft in- sdt2t pvc
G OR•TIIBING:-eoilierma7 closed `: ."=•-' °:
Company Name C� n C�`O DI � ! �C Fss MATERIAL
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2.Well Construction PermhtY: ft• ft `m.
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List all applicable well consA•uctionpermits'(se.UIC,Couniv,State,Ymzaace,eicr fL xt in -
3.Well Use(check well nse): _ . ..:.`_'} ;;•;.. r;::�:`:•cl.. .�.;.•. .::.
. 17.SCR'EEN•,:r:..�`•-,. ~•1SLOTSIZE• •TATCTQZFSS MATERIAL.-.
[tAgricultaral
r Supply Well: FROM To DIAMETER
EMuoicipalRublic ft. ftrnthermal(He ating/COOling'Supp1Y) Residential Water Supply{single) ft ft stnaUCommercial _!Residential Water Supply(shared) ;8�R0��• :�� --,
FROM TO wrb7�grdT T MPT-4. M1 TROD&3M04I1T
F-:12"On p ft 2p � ben[ontle• ' poured
ter Supply Wen* ftringRecovery
Injection Well: ft ft
roundwater Remediation AVEL'Piga hirab
Aquifer Recharge 19:s2ND1GR PLI,[ NT t-,=DD
��;;��,,SalinityBasier FROM TO MATERIAI
Aquifer Storage and Recovery ft ft
Aquifer Test O Stormwater Drainage
Subsidence Control ft_ it
!Experimental Technology
Geothermal(ClosedLoop) Q!Tracer : '.DR1LLIITG.TOG'(attach'sdditioPTIONets10r,h soil ockty NS�etcl
RFROM TO D PTION(who,h ess,soillrock type,gza
Geothermal(HeatinglCooling Retum) .J Other(explainunder#21 Remarks) D ft
1)`3-ZZ Well lD# ft `� rt
4_Date Well(s)Completed: _ 6 ft ft
Sa.Well Location: ,q ft V"'
it ft
Fae ity{/Owneerr�Name Facility
�ID (if applicable)
� ft �...s
Physical Address,City,and Zip :21,a RMaRs .[:_l;:-'-i:•-_c - ,.:, 'i.,:::"• - -
41)a516A �vDEC 2077
Co ParcelIdentin-cation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 C tin
(rf'welllffield,one lat/long is sufficient) Q ) M /q�j<
2 N SY�. I -L W 5k Date+}-1!"
' Signature of Certified We}1 Contractor '
6.Is(are)the well(s)MPermanent or Temporary
By signing this form,I rl'I ekvCo certify chat the well(s)was(were)constructed in accordance
a well: ayes or I o with 15A NCAC 02C.0100 or I5ANCAC 62C.0200 Wo Construction Standards and that a
7.Is this a repair to an exisfinn FJ lain the nature a the copy ofihis record has been provided to theiwell owner.
If this is a repay,fill out known well consLucflon irifarmation esp of
the
under 42J 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 Gecprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells S� TAL INSTRUCTIONS
drilled: 1 QO
9.Total well depth below land surface: f CJ (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii fermi(example-3(200'and 2@100) construction to the following.
top of rasing: 'S (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top Ma
Ifwatr lire!is above casino use 1 1617 il Service Center,Raleigh,NC 27699-1617
m, ` 24b.For injection Wells: In addi ra to the address in 24a
tion to sending the fo
11,BorehoIe diameter: 6 (in.)
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: D construction to the following:
(Le.auger,rotary,cable,direct push,etc.) � ection Control Program,
Division of Water Resources,Underground Inj
FOR WATER SUPPLY WELLS,9NLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 within
Method of test air pressure 24c.For Water Suuuly&Injection iWeIIs: In addition to sending the dons to
13a.yield(gpm) y res the address(es) 'above, also submit onei copy of this form 30 days of
! Amount: / `� completion of well construction to the county health department of the county
j 13b.Disinfection type: / where consirafted_
Revised 2 22 2016
North Carolina Department ofEnvironmental Quality-Division of Water Resources
i
Form GW-1
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