GW1-2022-08575_Well Construction - GW1_20220906

— •14:3YATERZONE
G FROM TO ft
DESCRIPTION.•c
Well Con for ame '
R
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NC Well Contractor Certification Number
LS:OVIER.GASWG,(foi•multi=rasea wells)OR MT .R Cif
Morgan Well&Pump, Inc. : FROM TO' DIAMETER . TRICIMESS MATERrni.
Company Name +1 ft ft 6 1181 m sd21 pvc
���/� 1t`IIR�R CASII�TG 0 3•TOBI_G. eotIierma7
2.Well Constrnciionpermit;V: "� FROM To DIAMETER T=�s :~MATERIAL
List all applicable well construction permits•(t e.wc,Emig State,Variance,etc)• il ft. in.
IWellUse(check welluse):
fL ft in.
Water Supply Well:
FROM TO c •.DIAMETER SLOT SIZE .-THIC 0mq U&TERIAL.
f Agricultural 0MDnicipWPublic ft fL
5 !Geothermal(HeatiaglCooling Supply) �IResidential Water Supply(single) R fc in.
I Tndustrial/Commerci.al I Residential Water Supply(shared)
i 1Lii a'tlOn FROM TO ,MATr.RL43, - ErffL-4CED7FNTMETHOD&9MOIINT
Non-Water Supply Well: 0 ft20 it bentonite• poured
DM--it—ring Recovery R ft
jection.W_eII: - R ft '
—,Aquifer RechargeI Groundwater Remediaidon
:19:S2LQD!(=RAVEL'PACK
AgniferStorageandRecovery DSalinityBarrier FROM To hraTFurar.fL
LACEn�NrMETHOD
Aquifer Test DStormwater Drainage R
Nceothennal
Experimental Technology Subsidence Control R it
Geothermal(Closed Locp) r3Tracer 20.DRILLIIQGIOG(aitac7is3diriorislsleets.ifaecess
r (Heating/Cooliag Return) -i Other(explain under#r21 Rem R arks) FROM TO � DESCRIPTION cold,trardaesr,soillroek type grafusa etc)
�I5� � . 1 I.
4.Date Well(s)Completed 71- ` Well ID# 'I S• R 2. xx rt
a.Well Location: fc �+ ft
• ` R ft.
FaciLry Owner e I Facility]:[)'I(If applicable) R R
z03� (7ob1 c $�.• C sTc�ya N C- tL ft .:a. . r s.
hysicalAddress,City,and Zip ft ftl'
� 7077
CIO .' Unil
County ParcelIdentiiicationNo.(P124)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well meld,one k0ong is sufficient) 2 cation:
:3s. 27-76 -Nit . ALL - W
6.Is(are)the we or MTemporary Siv4-5-Ai'12-C
rtified Well Contractor
B form,I hereby certify that the wells)was(were)cOw"cfed in accordance
7.Is this a repair to an existing well. Dyes or *No wul 02C.0100 or 15A NCAC 02C,0200 F7e17 Construction Standards and that a
-JUXUr is a repairjifl out)mown well cant ruction idformation and explain the nature of the copy ofthii record has been provided to the well owner.
repair under 421 remark section or on the bade 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
n constructio ,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —TV--a (N 24a. For All WeIIs: Submit this form within 30 days of completion of well
For multiple wells List all depths y-&ffzreat(erample-3 tJ 00'and 2@J00) construction to the following.
10.Static water level below top of casing: b (ft) Division of Water Resources,Information Processing Unit,
If, level is above casiiro use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,BorehoIe diameter: 6 (in.) 24b.For Injection WeIls: Im addition to sending the form to the address in 24a
-1y� ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l L� construction to the following.
(Le.auger,rotary,cable,direct Dusk,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the foffi to
_7
/ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: l 715Z► completion of well construction to the county health department of the county
Where constrnUed.
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016