GW1-2022-09238_Well Construction - GW1_20221003

I m
2 om TO I
Well Co A ft. ft.
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NC Well Contractor Certification Numbet
l
15.0VXKFL-GAMNG,for w6us) R 10DZ u R C
1`1 9
Morgan Well&Pump, Inc. FROM TO* DIAAW s
MATERIAL
ft- S Ila/ dr:2I.._1Pvo
Company Name ro
16.-ReM CASING 01R�-TE)B= clb�6&10
I FROM I TO DIAMETER
2.WellConutructionPermitt s5q'M
List all applicable wefl construction pamits'(1.e LUG Cola4v,State,Varfo=e,etc.)- f, ft
3.Well Use(check well use): ft ..ft in
Water Supply Well:
I FROM I To DLOTETZR SLOT SIZE THTCTCNWS MATERIAL.
fL im.
Agricultural mmunicipalipahlic ft
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) in.
ercial QResidential Water Supply(shared)
Leis:-Cmouz:
I FROM TO MATERIAL 3MPLAC320M 1=0D 0
ply g'Supply
(�"
Non-Water Supply Well: 0 ft. .20 ft bentionite. poured
Monitoring Recovery ft ft.
Jnjection. ft. ft.
Recharge ao un dwater Rem c di ati qon - - . ..: •"7-7.
_,Aquifer qAND/GRAVEL'P f�-_XK ifffike U a
Agnifer Storage and Recovery OSalinityBarder FROM TO - MATERIAL EhJPL&CRMENTN=OD
_1 Aquifer Test 0stounwat-ar Drainage ft
Pi Experimental Technology DSubsidence Control ft
QhGeothermal(Closed Loop) 07ramr
I M FROM I To DFSMRIPTIPN(color hardmess,sail type�grmb sim;etc)Geothermal(HcdinglCoolingRetum) 00ther(explain under#21 Remarks) f" SO ft die+
4.Date Well(s)Completed: 11t.21 17 Well ID# 120 it -& ft. -
L ft
Sa. ell Location: I-so & '56 6c.
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F=Mty/C,vvnff.J10= Facility ID4(if applicable)
t2,Q fL fL
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Ebaical Address,City,and Zip ft. ft
-7 i
County Parcel Iden cation No.TV)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(n well field,one lat4ong is sufficient) 2 ratio
0�6,sgl N 10. "bqt) W
6.Is(are)the W1,11(4permanent or OTemporary rSL.Ma e f J':'.i',';d Well Contractor D�tte
g is form I hereby ce,-*that the wen(r)w=(were)constructed in accordance
and AW a
7.Is this 2 repair to an existing wel. 01 Yes or ffiNo 15rah r154 Nrc 02 C.0100 or I SA MCA C 02C.0200 Fefl Construction S*mdm
If this is a rep
air,JIB out mown weRconsLruction hiformation andesplain Die nature of the copy ofAii record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform
. 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 GVF -1 is needed. Indicate TOTAL NUMBERof wells construction details. You may also attach additional pages if necessary.
drilled.- SUBMITTAL INSTRUCTIONS
Total well depth below land surface: —(ft-) 242- For All Wells: Submit this form within 30 day5 of completion Of well
For multiple wells fist all depths#-d1ffFreW(ex= -3@200'and 2@100) construction to the following:
10-Static water level below top of casing. (ft) Division of Water Resources,information Processing Unit
.,f'wa-1,vel is above casino use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 2.4b.For Injection Wells: in addition to sending the form to the address in 24a
r D.-L-n Jr above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: LA construction to the following.
(Le-auger,rotary,cable,directpusl-6 r1r-)
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 AL-dl Service Center,Raleigh,NC 27699-1636
13a.Yield pm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
(gp m) the address(es) 'above, also submit one copy of this foma within 30 days of
-0 the county health department of the county
FOR
-Disinfection typ&�M' Amount: completion of well construction t
constructedwhere
Form GW-1 North Carolina Department ofEnvimmnentai Quality-Division of Water Resources Revised 2-222016