GW1-2023-00462_Well Construction - GW1_20230109

1.WkD.Qontracti ticn:
• •I4:.�d.TER ZONES
Well Co for amee mom TO I DESCRIPTION
ft :11
NC Well Contactor Cer4catien Number
15:OU2ER:Q&fflNG,(fai•mnlfi=case3wills)O91111TER(ifs'Iicahle):y:::;; ••
Morgan Well&Pump;Inc. FROM TO' DTdT?FTRR i TF1 M\MSs I WATERUL
Comp Yan Name +1 ft ft 61/81 J �� sdt21 pvc
FROM G OR•TIJB rI •edtlierma7 clo'sbd-Iou I
2.Well ConstructionPermit#: � V t,� FROM To DTdMFTP.R ��.n:,ss r~MATERIAL*
Sistallapplicable wellconst•uctianpermits'(ie,WC,County,Stale,Ymiawe,etc)• ft- ft
3.Well Use(check well use): ft tt in.
Water Supply We All: •t_
FROM TO DIAMETER SLOT SIZE lTETCKNESS .MATERIAL
Agricultural 0MunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) )!Residential Water Supply(single) ft
Commercial i Residential Water Supply(shared)
18:GRODT•:-;.' _ _ -•�; _:�•:.`_ _ - �: ;:.ir';�.; ti': ;::•,;_.�•-i•.
liri ation FROM TO l ore Rrdr. -gy p~ CEMENTMETHOII&AMOUNT
Non-Water Snpply Well: o ft 20 bentonRe• poured
Monitoring, Recovery ft ft
'injection.Well: - -
Aquifer Recharge 0 Groundwater Remediation„n rl
Aquifer Storage and Recdery S B N Q [ll''L �.SI,1YD/GRAVEL PACK�" licable ' :'.;:_''::'. •..',•';`•'..°•:;
almrfy FROM TO MATERIAL EhMACEMENTIv=03)
Aquifer Test D•StormwaterDrainages , �. ?tj ! �iL' ft. ft
t Experimental Technology �Subsideiice Cbritrol, �' i7 ft ft
1Geothermal(Closed Loop) 1p3-�,Tracer ;20.DRILLIlVG.IOG'attacfi'addition'sIs eeEs�fneces's-
r.
Geothermal(lieating/Cooling Retum) j Other(ERplain under#21 Remadcs) FROM TO DESCRIPTION(color,hardness,soll/.,k ty e,grain size,etc)
C) ft lY�
4.Date Well(s)Completed:% ell ID# 1 6: ft 1�
Oft
5a. ell Loti n: ` LI� R � , ��o�J� r�C��t._.. •
ra
Facility/Owner Name Facility ID#(�fapplicable) ft.
�G
Xt-
Physi7:5icfcyyll aAddress,City,and Zip ` ft t f
county e`.P Career Identificatien �IN) -J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,onela�t(long is sufficient) A 2 ca$on.
10,
6.Is(are)the well(s) fPermanent or OTemporary Signs YfrtE fied WeII Contactor Date
B gyrinform,I hereby cerizfy that the well(s)was(were)constructed in accordance
7.TS this a repair to an existing well:- K]Yes or.yNo wuh ISA 02C.0100 or 154 NCAC 02C•.0200 Fee➢Construction Standards and that a
FfY7us is a repair fzR out known we➢consh uc8on hjformatlon and explain the nature ofthe coPY ofthii record has been provided to the well owner.
repair under#2I remand section'or on the back ofthis 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 1 GW-1 is needed Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifneeessaiy.
drilled: y -
SUBMTITAL INSTRUCTIONS
9.Total well depth below I surface:
For multiple wells List all depths i y- Cfdi�erent(example-3 a�00'and 2@ (ft) 24a.For All Wells: Submit this form within 30 days of completion of well100) construction to the following,
10-Static water level below top of casing._ (ft) Division of Water Resources,Information Processing Unit,
.Ifwate•level is above casing use„+"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor:ehoIe diameter: 6 an.), 24b.For Imiecton Wells: in addition to'sending the form to the address in 24a
12.Well construction method:
±P 1((J above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(ie.sage,mtary,cable,d¢ectptish,etc.) �'. .
FOR WATER SUPPLY WELLS ONLY- Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test air pressure 24c For Water Sunniv&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit anti copy of this form within 30 days of
13b.Disinfecfion iyp Amount: �` completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
i ,