GW1-2022-09236_Well Construction - GW1_20221003

FROM TO DES
Well Co ame� 106d
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NC Wall Contractor Certification Numbet I I
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Morgan Well&Pump, Inc. 1 FROM TO' DIAM= I TXCMqEss MAT".—
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FROM TO D""IER T3310EMESS MATERIAL'
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2.Well Construction Permit ?111991,6
Zist all applicable well construadonpamits'ri.a Wa 0)u*,_StaLe,Vw-hmce,elc.J
3.Well Use(check well use): & !L ---------I—.---------
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THTCKNESS I MATERIAL
Agricultual C#Municipal/Fublic ft IL i1L
Geothermal(Eeating/Cooling Supply) ffiResidential Water Supply(single)
fr in
-
onmmercial derntial Water Supply(Share'd)
Ini 'on I FROM I TO I 19� EMPLA �nn z I I MTDIT
Non-Water Supply Well: a ft 20 ft. bent'Dnite. poured
Monitoring
nRecovery ft. ft.
_1hjecfion.W_eE- ft. ft.
Aquifer Recharge Groundwater Remediation
Aqaffm Storage and Recovery DSalinifyBanier I MATERIAL METHOD
0 Supply
(Sharoc)
TNNon-Water
M
.Uecft.
_If- 1
.r mton
Aquifer Test OStormwater Drainage IL ft.
I Experimental Technology OSubsidence Control ft. ft.
Ex
perimental
(Closed Loop) Tracer
C
I FROM I TO DESCRIPTION(-ulor,hard-esqs�son/mck type,grair,size�eto
Geothermal(Heating/600 Retum) 00ther(explain under#21 Remarks) 1 0 It its f,
4.Date Well(s)Completed: 114Wel1ID# is fL 11+0 ft ibauw.
0 ft D Sa.Well Locati
AO
ft.XL AM 1 .1 2-W ft-
Facffity/OwnarN4 Facility ID#(il'applirable) ft. ft. 0 1'
2Lb L%6 Wtd ft f,
ft. ft. 'r, I.
dress, 7-
Physical Address,City.and Zip
CY5G. Iowa
County Parcellden cationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ffweU field,one lat4ang is sufficient) 2 cation:
-.3cs,(.��rl -N W a:7/2— — Zv
6.Is(are)the wells)Vermarent or UlTemporary S is
We"Contractor ate
z s)was(were)constructed in accordance
m,I hereby cent5�that the well(or'Dyes or INNO,
7.Is this a repair to an a:dsdngwelh Xie1_,7_M54.1-VC 02C.0100 or 15.4JVCAC 02C-.0200 WCH CDNSiMCdOn&and--dr and that a
If this is a re copy ofzhii record has beEnprovided to the well owlier.
.pafr,fiR out known well construchan idformadon and explain the nature of
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/I)PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro-vide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessaxy.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Art all depths jf&ffErew(=mnple-3(a 200'mid 2@100) construction to the following.
10.Static water level below top of casing. 46 (ft) Division of Water Resources,Information Processing Unit,
I fwater level is above casino use 1617 Mail service center,Raleigh,NC 27699-1617
11.Borehole diameter: 6
(in.) 24b.For Iniection Wells: In addition to sending the foram to the address in 24a
above,also submit one copy of this fora within 30 days of completion of well
12.Well construction method: 0+L1 t-
Cie.auger,rotary,cable,directpusk eta) construction to the following.
FOR EWATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Inj ecdon Control Program,
1636 Mail Service Center,Raleigh,NC 27699-163 6
1 (gp-) Method of test: 24c.For Water Surmiv&Tmiection Wells: In addition to sending the fbim to
13a.Yield air pressure
smf6c
I - : _to. S07 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ [MIM/ Amount:
completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2222016