GW1-2023-00574_Well Construction - GW1_20230109

rvc Well ConhadDrCettWcationNmnbet
Morgan Well&Pump Inc. >5.O�c�snv�(fDrmniti=�eaW�{oRzn�(�t - veible)�
FROM T DIAMETER I THIMa ESS MATER7hL
Company Name +1 l ft. ft 61N ; in. sdr2t pvc
.�� � I6:7PII�R 012.TUB7NG 'eotIiermslclo's@d_'Od j':."° •: '•:.':,.,
2.Well Construction Permit4: � FROM TO DIAMETF1t THICF�SS MATFR2L4L'
List all applicable well construction permits a U1C,Couniv,State Parlance,etc)- R fL in
3.Well Use(check well use): it ft ' in.
Water Supply Well: Iz-SCREIIQ;
Agricultural 014unicipal/Public VRoM TO DIAIYIETER� SLOTSiZE ^THrUCIMS rMATEML
ft fL in.
Geothermal(Iiesting/Cooling Supply) WResideatial Water Supply(single)
induEstft,30Commercial I Residential Water Supply ft ft hL
'Ini atiom — PP Y(Shared) ;;78rt$tO11T. _ = a•_ - -
FROM TO 1yATMUAL is +fig' CEMEKTh ETH011&9MOUNT
Non-Water Supply Wen-. o ft 20 ft '
bentonite• poured
Monitoring. DRecovely ft ft
Injection.WeII
—,Aquifer Recharge DGroundwaterRernediation ft ft
Aquifer Storage and Rec6i cry Salinity Banter �:SAID/GRAVEL'P9 -
FROM TO MATERUL EMPLACEMENTiASMOD
—I Aquifer Test 13Sto=vvater Drainage ft ft.
Experimental Technology rj Subsidence Control ft
Geothermal(Closed Loop) 13Tracer
:20.DRILLII?G.TOG'(attaclPiddUffils:ieetsifaecess
r. Geothermal(Heating/Cooling Rcturn) J Other(explain under#21 Remadrs) FROM TO DESCRIPTION(color,bardness,soil/rock type,rain size,etc)
.& ft )
4.Date Well(q)Completed:« �1 � Well ID# ' ft. ft
Sa Well Location: ft C) ft
ft ft >
FacUity/OwwnerName . ( �Fyaaccilittyy (ifapplicable) ftwkOL ft ft
//��
P Addddmss,fCiittn and Zip � ft. fL T
RYA ➢ �' •��� :7Ii-R1,`MA.RITR�:r.': ,: `.J: _ - --!,%' - _c•'-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ±
Cifwell field,one le/long is, cient)
�(� 2 cation
6.Ts(are)the weIl(s) Permanent or OTemporary 8iPa f rtified ell Contractor Date
7.Is this a repair to an eidsting Well: or.Y , B gn'no is form,I her-ebv certify that the wan(s)was(were)constructed in accordance
Q �No wuh
-Phis is a re 1511 C 02C.0100 or 15..4 NCAC 02C,0200 Well Construction Standards and that a
pair,fill out known well construction information and explain the natwe ofthe copy offM record has beenprovided to the well owner.
repair under#21 remarks section-or on the back off&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 TOTALNUMBBR'of wells construction details. You may also attach additional pages ifnecessary,
drilled:_ y
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multrple'wellsbstalkdepMsifdjffrent(example-3@200'and2@100) (�) 242• For All Wells: Submit this form iwithin 30 days of completion of well
construction to the following.
10-Static water level below top of casing: A o
.Ifwater level is above casino use••+-- (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
I1.BorehoIe diameter: 6 (in•)'
24b.For Infection Wells: In addition to sending the form to the address in 24a
~_12.Well-constructionmethod:_- 1`-� �L� above, also submit one copy of this fomi-withm 30 days of completion of well
(1-e-auger,rotary,cable,directpush,etc.) construction to the following.
E13b.
WATER SDPPLY�Va�I�LSNLX: Division ofWater Resources,Underground Injection Control Program,
1636Maii Service Center,Raleigh,NC 27699-1636
Yeld(gpm) • Method of test: art pressure 24c.For Water SuuuIv&Iniection Wells: In addition to sending the form to
Disinfection Q the address(es) 'above, also submit one copy of this form within 30 days of
tYP Amount:_ � tl (7— completion of well construction to the county health department of the county
where constructed
Form GVr-1 '
North CruniiaaDeparkuent of ErzvirDumenta �lnsl�i}=I�Iv1Sion of i rtb C2101ina Deoe E r1QM24ffi6M
an tal
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