GW1-2022-10837_Well Construction - GW1_20221209

Well Contr for ame FROM TO I DESCRIPTION
ft ft i
l r R ft
NC Well Contractor Cer6gcation Number
� 'I5:OU�ER•G6$]1\TTC�,(fn"r multi=caked wells)O�2 L•Il`�R(ifa'licable)'1:�::'.:,::'•.".=
Morgan Well&Pump;Inc. FROM x nLangTfER TEacrugms I,�ATEIUAr
Company Name +1 ft ft 61181 I in sdd11 pvc
I I6. II�R CASING_R-T[1B7P7G. eotIeriinal closed rid": =
2.WellConstructionPermft#: FROM TO DTaM'ETER I THICKNESS rI MATERIAL'
List all applicable well construction permtt4(ie•LUC,Cow*,State,Viviance,etc} f• ft I in.
3.Well Use(check well use): ft. ft. I I m-
ater Supply well:
W 17 BCREEN',,:.: - .' ,. •._=I:- �;� (:: .::;:• -�.:
FROM TO DrAMRTER. I SLOTSTLE ,.THICKNESSr -..IYUTERIA'L
Agricultural DMunicipaUPublic ft fL in!',
y i Geothermal(Eieating/Cooling Supply) DResidential Water Supply(single) R " fL �p
Tndustn Commercial UResidential Water Supply(shared) :18.GROUT -
Irri ation I FROM TO " - NrA•t•Fu AL La cnffNnMETHOII&SMOUNT
Non-Water Supply Well: o R 20 ft bentonites' poured
Monitoring DRecovery ft ft
-[Injection.WeII:
ft ft I _
J Aquifer Recharge GroundwaterRemediaiion
Aquifer Storage and Recovery D Salinity Bawer FROSALID/GRAVEL Pd CS ATA�ff hre :.:�: `:: 'IZTAL Ei,2LkCEMFNT 1V11$OD
'Aquifer Test 0Stormwater Drainage ft ft
1 Experimental Technology [3 Subsidence Control ft ft
Geothermal(ClosedLoop) OTracer :20.-DRILUNG.DOG'(attacliadditionEIslketsjf -g••'.' -;-'.V:
Geothermal(Heating/Cooling Return) i Other(explain under 021 Remarks) FROM T}OQ DESCRIPTION(color,hardness,saiVrocklype grain Size,eta)
4.Date'Well(s)Completed:•JQ, l Wel1ID# '�. fr �� ft' L
Sa.Well Location: fL
ft ft
Facili /OwnerName J Facility IDO Cif applicable ft.
fL ft
Physical Address,City,and Zip ft ft 022
'�y��� 'ZIB"Ft�7f2aRuS'- «;.- `:f- 1R4:vl,:ri~i;N;.�+` :.:=.:";.:':_�;,.:•:
vtret• t=y .y g Ur;q
County ParcelIdentificationNo.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lattlong is sufncient) 2 ration i'
35.Sri I3 -N ®.W0% ' W
6.Is(are)time well(s)*Pernranent or Temporary Signa e f ed Well Contractor Da
B o in,g is farm,I hereby ceit fy that I the,well(s)was(we
constructed in accordance
7.Is this a repair to an existing well• ©Yes or•f Nc wuh ISAN C 02C•0100 or ISA NCAC 02C:0200 FPeII Conshuction SYandardr and that a
Shirts is a repair,fill out knOwn waF consL•ucdon information and explain the nature of Me copy ofthii record has been provided to the.well owner.
repairunder 421 remarks section'or on the back of this form I
23.Site diagram or additional well details:
8.For Geoprob'e/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,only 1 GW-1'is needed. Indicate TOTAL NUMBER'ofwells construction details. You may also attach additional pages if necessary.
drilled: ' 1 I
SUBMITTAL INSTRUCTIONS j�
9.Total well depth below Iand surface: 30a (ft) 24a.Far All Wells: Submit this form within 30 days of completion of well
For multiple welh&I all depths ifdifjerent(ermnple-3 a 00'and 2Q100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form witbm 30 days of completion of well
~12.Well construction method: construction to the following:
(I.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY-_ I636 Mail Service Cent or,`Raleigh,NC 27699-1636
13a•Yield(gpm) SIG Methodof test: air pressure 24c.For Water SuupIy&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
113b.Disinfection typ fflM, Amount: ID completion of well construction to the county health department of the county
where constratted-
i
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
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