GW1-2022-08587_Well Construction - GW1_20220906

•14:.PiA TER ZONEs:.
I FROM j TO DESCWTION
Well Co for are ,
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NC Well Contractor Certification Nmnbet 15.OUT5Tt-eASING,00;i!multi sea sveIls O .Z. PM Cf livable'
Morgan Well &Pump, Inc. FROM ni•* R ` Tmc»ss MATERIhL
+1 R O ft 6 1/81 I m' sd,21 pvc
Company Name ICINMC6SINC- OB•TUBIIN'G.•edtIiermalclosed-1oo`:.:~•
2.well Construction Permit#:� � FROM TO DIAa�TER T8r( SS Me7ZZRiat'.
Lint all applicable well construction permrls'(Le,r1IC,Coutrtt,State,Variance,etc)- R ft.
ft ft fn
3.Well Use(check well use): -
Water Supply Well: FROM To nuMEm sx sI oT srzF rx[craMs MAT>Iunl .
Agricultural MMunicipwPublic R R in.
i Geothermal(Heating/Cooling Supply) MResidential Water Supply( e) ft ft in-
I ercial JResideutjal Water Supply(shared) .18rGROUT::• _ ^':'., ` >'^•-' %.: 1st` ::p;
'on FROM TO ,MATERIAL EMPL4CEMFNTMETHOD&AMOIINT
Non-Water Supply Well: o R 20 ft bentonite- poured
t Monitoring DRecovery R ft
Snjection.Well. R ft
Aquifer Recharge 3 Groundwater Remediation
'.19:SAND/GRAVEL-PACK if app cli 15le
Aquifer Storage and Recovery !Salinity Bawer FROM 7,ff I MATERIAL EMPLAC&MENT METHOD
Aquifer Test Stormwater Drainage R ft
t Experimental Technology DSubsidence Control R ft
Geothermal(Closed Loop) EIT=rr :28.DRILLdNGZOG'aitac]iaddifiiinalsheeEs�ffiecess 7' -_ .' 'r ',
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM R TO DESCRIP ION(color,hardaess,soillrock(9PS �)
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4.Date Well(s)Completed:q�( Well ID" Ito. ' 30
Sa ell Loran�j ( ( 3� R $� ft
ac
ft ft.
Facility/Owner Name Facility ID# applicable) �y Q ft
fL ft.
ekdrta* %
Physical Address,City,and Zip R ft
County Patcel Identification No.(PUN) urlu
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Atwell field,one lat/long is sufficient) 2 cation'
35.;usq q -N Sol, i5 l q W � �
6.Is are the wells ermanent or !Tem or Sirf�A-
tined Well Contractor DaiE/—-
( ) () p
B is form,1 hereby certify char the well(s)was(were)constructers in accordance
7.Is this a repair to an existing well: Dyes or ONO wttli C 02C_0100 or ISA NCAC 02C:0200 WeH CD=h'uction Standards and that a
Ifvds is are fill out)mown well construction information and explain the natw•e of the copy ofthis 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 GeoprobeMPT or Qosed-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 TOTALNUMBER'ofwells construction details. You may also attach additional pages ifnecessary.
drilled: `� I tit-, SUBMITTAL INSTRUCTTONS
9.Total well depth below land surface: 4S-1— ft) 242.For All Wells: Submit this fotm within 30 days of completion of well
For multiple wells list all depths#-4i fereni(example-3Q200'and 1Qa 100) construction to the following:
10.Static water level below top of casing: Zo (ft) Division of Water Rasa nrces,Information Processing Unit,
If water level is above cas6ta use"+" 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
I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 L� construction to the following.
(Le_auger,rotary,cable,dsectpusb,etc.)
Division of Water Resources,Underground Trajection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
132.Yield(gpm) O Method of test: air pressure 24c-For Water Supply&Injection Wells: In addition to sending the form to
(yam the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount L V completion of well construction to the county health department of the county
where construbted
Form GW-1 North Carolina Department ofEnvironmmtal Quality-Division of Water Resources Revised 2-22 2016