GW1-2023-00567_Well Construction - GW1_20230109

IV(;Well Contzctor C"4cation Number - rc, ft' '
Morgan Well&Purn 'Inc. Is:o ltc�sar9(ir�t_,�eaw�)CLA (if
p, FROM TO DLUMMTER TSICFfi Ss MATERIAL
Company Name �] +1 ft' G ft 6 i/a/ sdr2i pvc
I Well ConstructionPermit#: , i I OR.TQBING 'eot5ermai'cio'sedlod" �' ;'Q .s ;:%:,•,. •'
6 DZAIV�TER THICFi7�SS M 4TERIAL
List all applicable well co FROM TO
nstrucdon permits(ie UIC,COW4R Stale,Trarh ce,etc)• R .
i
3.Well Use(check well use): ft ft
Water Sn I
FP Y Well: Y'z-S CREW,
;,.:.: :€-_ �.. - r.�.-_ . i�- : ..-•� - -. . . ,
Agilculillral FROM TO -�.DIAMETER I SLOT SIZE THrcmms MATERIAL
�Mnnicipa]/Public ft `fL
GeOthemlah(Heating(Cooling Supply) &!Residential Water SuPPlY(ogle)
II—ndus Commercial 'n
J Residential Water Supply(shared) QtOTJT::. _
Non-Water Su I W FROM M TO ATRRrar JEIIP iCEMENTMETHOD&AMOUNT
PP Y eIl: 0 fL 20 ft
Monitorin bent
g onite• poured
Recovery-Injection.We1I• ft. ft. -
JAquiferRecharge DGroundwaterllemediation ft ft
Aquifer Storage and Reod�erySalinity Barrier :�:��/� POCK if a'•lickblb
FROM TO MATERIAL 'Eil�LACEME1VTi1�TgOD
I Aquifer Test oStoanwater Drainage ft ft..
I Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) 1ITracer ;20•DRMIZNG..L09C�E1 ddi[ib& sheetsjfaecess'
Geothermal 7'=�::-� •'= .'''i
r. (HeatineCoolingRetum) J Other(explainundes#21 Remarks) EOM jTO DESCRIPTION(color hardness,soi!/rocktype,grainsi�etLl
ft
4.Date WeIl(s)Completed: -77
ID# f, ft r
Sa Well Location: AA
ft. ft Y15
11
Facility ID#(if applicab]) ft ft
tt ft
Physical Address,City,an Zip _
6 5�4�('� �.7.IER'EMARKc=`- - •- r-_�^"�__._ e.� .ice y .1
Coonly
ParcelIdentificationNo.(PIN) IAN 'A1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal
q
«well field,
�one
,IaWong is suf cient) ritual degrees:
ration: l;iC;::: a .t :'i:''•v.;. :� d„u:
6.Is(are)the well(s) Permanent or oTemparary Z p
Si9na f f ed We}1 Contractor •Date
7.Is this a repair to an existing well Dyes or.ffiNo B gniug is farm,I hetebv cerdfy that the wells)was(were)constructed in accordance
wuh ISi!t C 02C_0700 Or 15d NCAC 02C:020O Well Conshucdon SYandmds mid that a
Ifliis is a repan,ftll out known well consL•ucSon information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section'or on the back Ofthiaform.
23.Site diagram or additional well details:
8_For Geoprobe/DPT or Closed-Leop C:eothermal�(te is haying the same You may use the back of this page to provide additional well site details or well
constmction,only I G 1W h is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:_
9.Total well depth below Iand surface: SUBMITTAL INSMUCTIONS
_ ��j„�,,,3 (fL)
For multiple wells list all depths ii erew(ermnple-3(�00'and 2@1009 24
a For All Wells: Submit this form within 30 days of completion of well
construction to the following.
10.Static water Ievel below top of casing:
IU'Water level is above casino use +^ (ft-) Division of Water Resources,Information Processing Unit,
11.BorehoIe diameter: 6
1617 Mail Service Center,R2leigh,NC 27699-1617
'
24b.For Infection TPeTT In addition to sending the form to the address in 24a
12.Well construction method:- 1`-0 L� above,also submit one copy of this form within 30 days of completion of well
a auger,rotary, d�ctpush etc.) construction to the following:
(i
FOR WATER S1&70NLY,LY WDivision of Water Resources,Underground Injection Control Program,
6 1636 Mail Service Center,Raleigh,NC 27699 I636
13a.Xield(gpm) Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the farmto
13b.Disinfection Amount: e �s(es) 'above, also submit one copy of this form within 30 days of
completion of well construction,to the county health department of the county
where coristiiibled=___....:.. .
I e m GW-I Dlort]i'Curolinii Depa kinerit f7$BNidirimnentaiZrlfty"Division of watecResource :9 r,.r._r t;ra new Re9isepi
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