GW1-2022-09711_Well Construction - GW1_20220907

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NCWellCmftctorCetificationNumbet '15.0U.�i�G9SIlIG.(fncmnlfi edw�s bltL7 tf _ �csble' ::::•.•:' .'.:
Morgan Well&Pump, Inc. 1 To nl1/81 R
TSICKNEi SS MATERIAL
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Company Name G OR.TGBI146 eotliermal
y / FROM TO DIAMETER t ITIacKI�ss MATERIAL'
2.Well Construction Permit#:, DO 1r1 in
List aV app&able wen cansmwXanpmn ifsAe.Ult;Cawiv,State Vm1ance,etcf ft 6
fL ft m•1
3.Well Use(check well use): I ; : ..--:`.,: 7• K;;':•:,
Water Supply Well: )ROM TO 'DIAMET&& SLOT sm TBICKMS MATERIAL.
_Agricultural r3ManicipaUPublic ft ft in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fc in.
Ct>mmercial Residential Water Supply(shared) .
:FR GROUT::•...
.� FROM TO - EDO?LA TMETSOD&AMOBNT
Non-Water i Well: 0 fL 20 ft bentonfte- Poured
DPP y
t Monitoring nRecovery fL ft
snjection.WeII ft. ft
er Recharge I Groundwater Remediaiion
_Aqurf .-9:SAND/GR.AVEL-PACg of ...lirs5le :.::.'�::": :_ ::'• ..
Aquifer Storage and Recovery DSalinity Banner FROM TO MATERIAL MOLACFd�NT METgOD
Aquifer Test Stormwater Drainage ft ft
I Experimental Technology Ei Subsidence Control ft -
Geothermal(Closed Loop) �ITracer
:20.7DRILLIZIGLOG'(attacli�3difionslsheefszfae
FROM TO DESCRIPTION color hardaess,soilhock
Geothermal(Heating/Cooliag Return) �Other(explain under#21 Remarks) I-�CP it
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4.Date Well(s)Completed?/ it.
Well ID# (0 ftft.5
5a WeTI Location:
1 R ft
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FacB'ity/Owner Name Facility ID#(rf applicable)
sib'R�tz.064� L"'k, �r- ft
icalAddress,City,and Zip ��� ft ft.
-2Ii-R`fi'MaRTIC`� •:�:.' `•i: =ter Y� :'�iwtr•:,.-�,rr�._
Comity Par d1d-- ationNo.(PIN) SUE 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t j n;i
C>f well field one lad/long is sufficient) �77� A]SA
cation:
ed Well Contractor
6.Is(are)the well(s) Permanent or OTemporarp
is form,I herebv cahfy that the wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONO C 02C.0100 or ISA NCAC 02C..0200 F7en Con-Cdon& dmds and that a
If this is a repair,fin out known wen construction idforn=bn and explain Die nature of the copy oftW record has been provided to the well ownerr,
repair under 411 remarks section or on the back of ibis form. 23.Site diagram of additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUNMER'of wells
drilled: `� SUBMPTTAL INSTRUCTIONS
9.Total well depth below land surface: ZM (ft) 24a.For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths if dlfferew(erample-3 eQ200'and 1Q100� construction to the following
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 Cn•) 24b.For Injection Wells: In addition to sending the fDmn to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C-Al construction to the following:
CLe.auger,rotary,cable,directpvsb.eta)
Division of Water Resources,Underground Iaj ectioa Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a Yield(gpm) •� Method of test: air pressure 24c.For Water Suuuly&InieetiOn Wells: In addition to sending the fora to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: �i completion of well construction to the county health department of the county
where constructed.
ty-Division of Water Resources Revised 2-22 2D16
Farm GW-1 Nortb Carolina Department of Environmental Quali
i I