GW1-2022-10242_Well Construction - GW1_20221111

Well FROM TO DESCRIPTION
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NC Well Contractor Certification Nunibet
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Morgan Well &Pump, Inc. FROM I TO
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Company Name +1 T sd2l pvr
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2.Well Construction Permit TO DTdMTTPii f =22MS hLtTERIAL'
Lie all W&-able weV construafibnpermitr'rl e LUCK Countv,S=4 Variance,etc)- ft ft
3.Well Use(check well use): ft
Water Supply Well: I Iz FROM I in ritkIKEMR. TffrcKms i-TVIATERIAL
Agricultural DMauicipal/Public; ft
f, in
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft- in.
I Commercial � Residential Water Supply
(shared) GROUT-.'-.-
'on FROM TO IgAlEpjAL X-ApLA.CENJM h=OD&AMOUM
Non-Water Supply Well: 0 ft 20 fL bentonfte- poured
1 Monitoring Recovery ft. ft.
-Injection ft ft.
Aquifer Recharge 13Goundwater-Re=diation
-19:SARD/GRAYEL.2
J!. I'�����2 C=X iff, U
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a S Monitoring
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ply
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Aquifer Storage and Recovery DSalinityBariier FROM MATERIAL rr METHOD
Storage
and Recovery
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Aquifer Test Stormwater Drainage ft
Aquifer
Subsi
dence
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I Experimental TerhnoloM7 OSubsidence Control ft.
Geothermal(Closed Loop) OTrarrr s
FROM TO DESCRIPTION(color,hardnem�sollftck B,
Geothermal
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Geot im (Heating/Cooling Return) -J Other
[Geothenmal(Heating
I d�..tin_)Cooling Retum) 00ther(explain under#21 fL 1,10 ft
4.Date Well(s)Completed:.10-k[2z-- Well JD# ft DL5 f,
S2.Well Location: I t rS ft So f,
In MAI L—t 1,50 &.1 eloo
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IF-ffty/bvvneT]4axne Facility M#Cif applicable)
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q41 III& AIL 281( fL
- Nr1V 1 2022
Physical Address,City,and Zip f, ft
-ajus
County Parcel Id— cati—No.(PIN)
5b.Latitude and longitade.in degrees/minirtes/seconds or decimal degrees:
ffwell field,one lattlong is sufficient) 2 cation:
ox., -N W
Wig ZZ
"It,Well Contractor DatJ
6.Is(are)the well(s)Verinanent or OTemporary SLI�13 c
is form,I hereby c.#y' that the wells)was(were)constructed in aCCDr&V=
Vand-
r54 NrC 02
7.Is this a repair to an existing welh Llyes or JoNo Y02 15A C.0100 or ISA IVCAC 02C.-0200,WeE CbnStrucrio?]S -ds and diar a
ofzhii record h=been provided to Me well owner.
.f1this is a re.pah-,fiR out known weZ7 construction Ldformation and explain Vie nature of the COPY
repair under#21 remarks section or on the back qf this 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 OW-1 is needed. Indicate TOTAL NUMBER bfwells construction details. You may also attach additional pages ifarcessary.
drilled. VI SDB=AL INSTRUCTIONS
M9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 dayt Of completion Of well
For mukiple'wells&I ail depths if different(Er=ple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing. (ft) Division of Water Resources,=ormatlon Processing Unit,
I fWater level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 2.4b.For Infection WeIls: In addition to sending the kim to the address in.24a
above, also submit one copy of this foul within,30 days of completion of well
12.Well construction method:
construction to the following
(1-r-auger,rotary,cable,directpusk eta) j
Division of Water Resources,Underground Injection Control-Program,
FOR WATER SUPPLY VV=S ONLY 1636 Mail Service Center,Ralei
gh,NC 27699-163 6
13a.Yield(gpm) Z Method of test air pressure 24c.For Water Suppiv&Iiiiection Wells: !In addition to sending the foun to
0 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ .h Amount•
f). completion of Well construction to the county health department of the county
where construbted.
Form GW-I North Carolina Department c)fEnvim=cmtal Quality-Division ofWaterResouices' Revised 2-22-2016