GW1-2022-03189_Well Construction - GW1_20220307

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Well ContractorName FROM TO 14:.WATER ZONES,'. •DESCRIPTIO%N r
55, 7Z ft ft
NC Well Contractor Certification Number ft f
Morgan Well&Pump, Inc. 1s:o GAS�*G',(f0i•multi=ca�eaw;: O_III t(ifa"Iicihle)'.y
FROM TO' DIAMETER THICKNESS MA IA'
Company Name 2 +1 ft. ft 61/8l in' sd121 pvc
2.Well Construction Permit# cJ �471C 16 CA`SWG OR•T(IB]1VG.' eotheimal'cto'sed rod' ''•; =•
9 J FROM TO DIAMETER THICKNESS List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.)• ft
ft. 4 in. MATERIAL
3.Well Use(check well use): ft. ft in
Water Supply Well:
w Agricultural FROM TO DLkMETER .�DMSLOT SIZE' •.YTAICKNF,SS MATERUS.,
"Pd -I/Public ft ft. in
Geothermal(Heating/Cooling Supply) ' esidential Water Supply(single)
I]^ndustrl ft ft
Commercial in.
J Residential Water Supply(shared)
1 lui ation ::18:GROUT•.
FROM TO - MATERLSL EMPLACEMENT METHOD&4MOUNT
Non-Water Supply Well: 0 ft 20 ft •
bentonite poured
'Monitoring Recovery
Injection Well: ft• ft
Aquifer Recharge Q Cn-oundwater Remediation ft ft
Aquifer Storage and Recovery 0$ ty Bw .19:SANDIGRAVEL PACK if a"liable
FROM TO MATERIAL ^ •.�Aquifer Test �StormwaterDrainage ft ft EAAFLACEMENT METHOD
J Experimental Technology OSubsideace Control ft
ft
Geothermal(Closed Loop) OTracer 20.tiRTLLIb1G.L'OG'(attacti sdditibhiAl sheets if nec
Geothermal(Heating/Coolines's"
FROM TO g Return) Other(explain under#21 Remarks) DESCRIPTION(color,hardness,sail/rack type grain size ere
4.Date Well(s)Completed•`�—`Lg-2� pith 1D# ft `7� g• r
�t:1�1' ale- OitL�
Sa.Well Location: L` ft ft. �VzX I 4
�OJ/�VQ �{61•( 1� ✓� ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
s ft ft.
222r� C 1 cjr r 7 �'1
Physical Address,City,and Zip ft ft
„ .�y F, n, .•., •.
County Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L A7(ifwell field,one lat/long is sufficient)
2022
c� t p j �+ C f 22.C tificatio
> Z l6 I NJ b�JS�lr� W J '1
6.Is(are)the well(s) Permanent or ©ITemporary Signature o Ce e
7.Is this a repair to an existing well: QYes Or By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
o w th 1SA NCAC 02C_0100 or'IS NCAC 02C•.0200 Well Construction Standards and that a
If this is a repair fill out known well construction information and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back 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 or well
construction,only I GW-I is needed- Ind.icate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled:_
O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f£)
For multiple wells lest all depths 1fdifferent(example_3 200'and 2Qa 100) tea• For All Wells: Submit this form within 30 days of completion of well
//`` construction to the following. .
10.Static water level below top of casing: 7-
Ifwoter level is above casing,use"+^ Vt•) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method- ( Q L� above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpusli etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water SuppIy&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: /�n Amount: G completion of well construction to the county health department of the county
where construtted
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2 22 2016