GW1-2022-09273_Well Construction - GW1_20221003

I Well ame FROM TO DESCStrPTtoir
& ft.
fL fL
NC Well Cant actor Certification Numbet ffioi ti�6ased We W.
0VXER.4A9JNG,(16r [is)Cff
Morgan Well &Pump, Inc. FROM I TO
+1 ft. 6118/ sdr2l pvc
Company Name 111 (015 ' • " '. ,..' '
I I CD�CA-qNG 0kT1JB1VX,'G- 'idthiffill I
FROM To TMCMMSS
2.Wall Construction Permit#: 2r,470-
LW all applicable well constructbn pcmits'rL e- Coibitv,State,Variance,Etc)- fL
& fL in,
3.Well Use(check well use):
Water Supply Well:
Lte�- FROM I TO D SLOT SIZE TMCKMS J�UTEKRUMAL
LAgricultural MMuaicipal/Fublic
Geothermal(Heatrig/Coohng Supply) JEResidental Water Supply(single)
QpResidential Water Supply(shared)
:'hri on I FROM I TO JMWOLA
Non-Water Supply Well: 0 ft 20 ft- bentionite. poured
Monitoring
nRecovery ft. ft.
-Injection Wem- ft ft.
Aquifer Recharge K3GroundWatrrRemediation I
PA:=(If
F-19:SAM/GR&VEL"
NPITIM11661116111" 4.1.,
(ogle)
'Ply(shared)
TN�n
Non-W ft
ft
ater'tor.
J
Aquifer Storage and Recovery nSalinityBarder I FROM TO MATERIAL jauLACEIdENTMMOD
Aquifer Test D&tcrmwaterDrainage ft.
Experimental Technology Subsidence Control. ft
:thern
Geothermal(Closed Loop) 13TMer 1:Z8.DRH=GJ;0G
FROM I To ESCRIPTION(calop hardness,s01-YrDtIctYP� sizp,efr-
Geothermal(Heating/Cooling Reftim) i Other(explain under#21 Remarks) .'t tlybw
4.Date Wells)Completed: Well M# I ft- 1 4 ft. br"yx
Sa.Well Location- Ad ` 1 90 :F' SauaA
L��hy%Location:
KwSYN 1 6 &.1 [.C) fl- 6 ru'-J Vx ra
Fac2lity/Ow=Name Fa�r M#(if applicable) 1 41c)f, I Soo ft-
a
ft ft.CuNcoy-A xc— V
21114,—QC
ft. ft.
Physical Adrlrtss'rity and Zip
County Parcelld— cationNo.(PIN)
5b.Latitude and longitude in degees/minutes/secands or decimal degrees:
(If Well field,one latdong is sufficient)
3 2 Cation:
6 2-6(0 'N �0-wgo
SL-'M f t ivd Well Contractor
accordance
6.Is(are)the well(s)#Permaneirt or E3Temporary f JT hw-aby cer*that the wefl(s)was(were)Wnstruc in accor
Da e
is form
,,RbjS'4� C.01000, VCAC 02C..02 0 pFen Const, on dtW-
7.Is this 2 repair to an existing welh []Yes or VNo 02 0
Jfr this is a reyairfiR out known well construction Ldformation and erplafn the nature of the copy of this record has been provided lo the well owv
rep
air under#21 remarks section or on the back of lids 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 G`W-1 is needed. Indicate TOTAL NUMBERof wells construction details. You may also attach additional! pages if necessary.
drilled: . I SUBMITTAL INSTRUCTIONS
9.Total well depth below land sm-face: Soo (ft-) 24a. For All Wells; Submit this form within 30 dayt of completion Of well
For mulfiple'wells&I all depths#'&ffere7if(krmple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing. 3's (ft.) Division of Water Resources,Information Processing Unit, -
f 1Water level is above casing.;Use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r 0. 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,directpusI4 etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ala Service Center,Raleigh,NC 27699-1636
132-Yield(,xprri) Method of test- air pressure 24c.For Water Supply&Iniection Wells i: In addition to sending the form. to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.DisinfectionAmount. 2_ completion of well construction to the county health department of the county
typ where constructed.
Form GW-1 North Carolina Department of Env* Revised 2-22-2016
Environmental Quality-Division of Water Resources