GW1-2023-02502_Well Construction - GW1_20230406

r.; _Pratit Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
.14.,- WATER ZONES s c` = =
FROM TO DESCRLPTION
We o ac rName ft. ft.
-34 L�Z ft. ft '
NC Well Contractor Certification Number 15:=0VIER;GA$ING:foemNti=ca"sed.@vells•OR'T�INERif:'a']iaable
Morgan Well&Pump, INC FROM T DIAMETER THICKNESS MATERrnL
�[�j 1 ft ft 61/8 m' sd21 pvc
Company Name ��(�®6� 1
S I6IlVNER'CASING=ORTilBI1`IG eotfierinahclosedaoo
2.Well Construction Permit#: FROM4fTO--fL
DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits�.e.UIC,County,State,Variance,etc.)
in.
ft. in.
3.Well Use(check well use): . _
17 SCREENS`
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural MMunicipal/Public ft. ft. in.
11 Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft ft.
Industrial/Commercial - Residential Water Supply(shared)
18.GROUT:
_Ihi ation FROM TO MATERLL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
:,)Monitoring Monitoring DJ Recovery ft ft
Injection Well: ft. ft.
C.Aquifer Recharge Groundwater Remediation
�—, 19.4SAND/GRAVIIPACK'rt:a
Aquifer Storage and Recovery LlSahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C_I Stormwater Drainage ft. ft.
J Experimental Technology COJ Subsidence Control % ft
U Geothermal(Closed Loop) (Tracer 20'3DRILLNG G O '(attacliadditiona
FROM TO DESCRIPTION(color,hardness,soillrmkp type, size,etc.)
-Geothermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) ® ft. ft. b
Y
4.Date Well(s)Completed:'g I Z- Well ID# t® % 3® ft.IL
try ft. ft
Sa.Well Location: V
ft ft
Facility/Owner Name Facility M#(if applicable) ft. ft
a �Cl� ft. ft <.•;>�.'3...- il...i .t:' •i., %•
Physical Address,City,and ft ft A P R
7
7—a-4aln, Ja 1 rat,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertification:
^? q N 0 3`46 W `s
6.Is(are)the well(s)MPermanent or J Temporary
SiZignohisfonn,
Certified Well Contractor Date
B I hereby certify that the wells)was(were)constructed in,accordance
7.Is this a repair to an existing well: nYes or JpNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction"Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks 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 if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��✓ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending-the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:
granulated chicane Amount: � completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

vy.mj,L UuiNb11000J_1UA.lttJ+'C O D (GW-1) For Internal Use Only.,
1.W ontractor I motion:
•14:WATER ZONES -
We11 Co for ame FROM TO DESCRIPTION Y
-A ft.
ft ft.
NC Well Contractor Certification Number \ '15:O'OTER,CASING,(fnc tnnitf=rased•yells)Q12I;II�.�12 Ctfa'livable)'
Morgan Well&Pump, Inc. FROM To' I DIAMETER THICE2NESS MATERIAL
Company Name +1 ft, I I)S ft G 1/e1 in, sdr2l pvc
/•/•yy'� 22 16.`DUOR CASING OR•TQBING.' eotfiermal•cIo'sed-ltio' j`:�:'''•a'<.•:'' '�'''
2.Well Construction Permit#: FROM TO DIAMETER TBICKNESS MATERIAL
List all applicable well construction permits'r e, LUC.Cow4p,State,par ance,eic.)• ft in.
3.Well Use(check well use):
ft ft. in.
VAgLicnItul-al
Supply Well: . 17.SCREII�r'.i::' !_- •'' .• -'`_ ::s:., ::,:a:;�. ;.:..:=•`
FROM TO DLAMETER =SrZET11TC131FSS IDIATERIAL.
0Municipal/Public ft. ft in•al(Heating/Cooling Supply) ®Residential Water Supply(single) ft ftCommercial Residential Water Supply(shoed) :;Y8:GROUT:_., _ - - '^": ::'=''• -[Geothermal
tion FROM TO MATERIALater Supply Well: 0 ft 20 ft bentonite- poured
toring Recovery ft ft.
n.WeII:
er Recharge DI GroundwaterRemediation
er Storage and Recoveryi SalinityBarrier goSgND/GRAVFS'PACK rTO T E AL EMPLACI MENT il7ETHODer Test [3Stormwater Drainage ft ft.
mental Technology Ij Subsidence Controlft ftermal(Closed Loop) OTracerrmal(heating/Cooling Retum) -i Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,scillrock type,e±•�cn size,efe)
r. 3 f, `
4.Date Well(s)Completed:3) Al Well ID# L ft /►�5 ft-
ell Location: R L 0 f,
(� ft l� ft
Facility/Owe Name Facility M#(ifapplicable) ft ft (�
Ck Aft ZSs114 t 3q Oft- l mitt,
sicalAddress,City,and Zip ft ft. I,-
- � f���� ��� :21:'RF.MARTIR°:,: `�i.•.;:.r '�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) _, l
2 canon: .. '- . •G.
x3
6.Is(are)the well(s)*Permanent or OTemporary Signrrg
eyfi
rtified Well Contractor Dat
B eorm,I hereby ce,tify Hrt the we71(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or fNe wuh I5 02C.0100 or 15,1 NCAC 02C.0200 YPell Construction Slandm ds and that a
.0'1721 s is a t•epair fzll out known well consL uction information and explain the natut e ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofihis farm. 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2(1009 construction to the following:
10.Static water level below top of casing: a�� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A LI construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 76991 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suuniy&Infection Wells: In addition to sending the form to
13b.Disinfection typ-PIA
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type ft completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources I Revised 2 22 2016

yy.mLJ-jt,UlNb1xtUt_:AIU.N RECORD(GW-1) For Internal Use Only.
1.W ontracforinf maticn:
•14:.WA-TF2t ZONES
Well Con for are . FROM TO DESCRIPTION
ft ft
-A ° t ft ft
NC Well Contractor Certification Numbet
.; '15:OU�ER:CASING,(fo"r multi=raked webs)bR I.lT1EJ.2(if a'licahle)' :�::`.�.::'•.`•=
Morgan Well&Pump, Inc. _ FROM TO I DIAMETER Talgagss MATERIAL
Company Name +1 ft i ft s 1/S/ in' s- pvc .
n w ��� 16.`RjNFR CASWG OR•TUB ING••eotfie Rl clo'se3ltiu":.
2.Wel1 Construction Permit#: (f�,) FROM TO DIAMETER THICKNESS List all all applicable well construction permits'(Le.UIC,Cowtiv,State,Variance,air-)- ft ft* in.
3.Well Use(check well use): ft ft. in.
11-SCREEN',.:.: :. - r•;:. ::.-•:_:.-yl.: "•' ...:
Water Supply Well: •.•.•:...•.�� �.,.•. ..•. .-.
• FROM TO DIAMETER SLOT SIZE THICKNESS 11•IATERTAL.
.-_Agricultural �Municipa]/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft �-
1n]Commercial _I Residential Water Supply(shared) :;z8.�0�•:.: •• __ _ - - -
Izri ation FROM TO MATERIAL EMPL4CEMENTMETHOD&_4MOUNT
Non-Water Supply Well: o ft 20 ft- benionite• poured
Monitoring I Recovery ft. ft.
Injection.Well; ft ft
_J Aquifer Recharge �GroundwaterRemediation s•.
;.-19:SAND/GRAVEL PA CK Cif a"licahle
Aquifer Storage and Recovery nSalinityBarrier FR�ftT
MATERIAL - EMPLACEMENT METHOD
Aquifer TestStormwater Drainage ft
I Experimental Technology [3Subsidence Control ft ft
Geothermal(Closed Loop) �ITracer :20.DRILLfI�TG.L'OG(aitacli-additiorisl sheetsiffiecets �', =s :6 •.' �::=%
i Geothermal(Heating/Cooling Retnm) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,ere)
c O ft �5 ft
4.Date Well(s)Completed:�3 Well 1D# 5, ft b ft
5 .Well Location: 1146 ft I ft
ftJsoo ft Y6•
Facility/OwnerNa L_ i.111Facility M#(ifapplicable) ft• ft
r ,
Physical Address,City,and Zip ft ft
qrz ask
County Parc-1IdentificationNo.(PIN)
5b.Latitude and longitude iu deb ees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) a��
N�% .(d3q� W 3
6.Is(are)the well(s) fPermanent or QI Temporary Signs e f ' ad Well Contractor •D e
B e ung it form,I he.ebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or �No with 15,1 C 02C_0100 or 15.4 NCAC 02C,0200 Mell Construction Standm-ds and that a
Ifthis is a repair fill out known weB construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back ofthisform. 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3co (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdiferent(example-3 cr 00'and 2@100) construction to the following:
10.Static water level below top of casing: 445 (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 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: )� LI construction to the following:
(Le.auger,rotary,cable,directpush,eta) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In.addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ rl" Amount: completion of well construction to the county health department of the county
where construtted_
Form OW-1 North Carolina Deparment of Environmental Quality-Division of Water Resources Revised 2 22 2016

WX,J,L k-l ilNbLMUCIIUA RECORD(GW-1) For Internal Use Only.,
1.71 ontracfor I •mation:
14:.WATER ZONES
Well Co. for am
e " FROM TO DESCRIPTION
2 �n�t , ft
—/ , ft
Al i r = ft ft I
NC Well Contractor Certification Number
I5:OIITEILf�ASIlI�,(for multi=casedw6us)bl; (ifa'licshle)'
Morgan Well&Pump, Inc. = FROM TO' DIAMETER TH[CKNESS MATERIa3
Company Name +1 ft• b ft 61181 In' sdO pvc
2 A 16.-INN CAS NG OR (B•TIING'(Y e6tiiecrmE cldsMAod"L;':.:'-`
2.Well Construction Permit#: J�� l� FROM I TO DIAMETER THICIGiEss MATERIAL
List all applicable well construction parmits'rL e.UIC,County,State Variance,etc)- ft ft• m'
ft ft.
3.Well Use(check well use): •r Water Supply Well: I7."SCREEN',:-:: - _•=• _ :z:. :.:•.._ ;.:. .:::
FROM TO DIAMETER SLOT SIZE THICKNESS hATERIAL.
Agricultural �Municipal/Public it ft in•
i Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft �•
I�ndustriaUCommercial I Residential Water Supply(shared)
:.1SiGRODT:;, =. =:'.'. ::'•:,."_:.._. : .a:•:,i; :=C .:•: +•- ;.
Ini ation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft bentonite• poured
Monitoring DRecovery ft. ft.
Snjection.Well. 2 ft
_I Aquifer Recharge I Groundwater Remediation
`Aquifer Storage and Recovery ni Salinity Barrier FRo / To L FAQ 11
MATERTAI,e EMPLACEMENT iMETHOD+"
_•Aquifer Test OStormwater Drainage ft ft.
I J Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) r3Tracer :20.TDRI[.LIIQG.L'OG'(atticli addition'sl Alieetsjfaecess
i Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(calo,hardness,soil/rock type gra n size ere)
c I� ft �D ft -
4.Date Well(s)Completed::� Well IDv ZV-D ft `SO ft
Sa.Well Location: St � 46 ft ��•
�y ft 2� ft
Facility/OwnerName -� Facility MN(if applicable) ft. ft
gyis S,.�WcLT_L <,.k6 c 2 `7 ft ft.
Physical Address,City,and Zip e l ft ft
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 2 cation:
3e, (Arlo N 4�ag;0JA 'W � a
6.Is(are)the well(s) Permanent or DTemporary Signa eZzy�
rtified Well Contractor Da e
B finingform,I her•ebv cer*ify that the wells)was(were)constructed in accordance
7.L Phis a repair to an existing well: Yes or �No wuh ISA 02C.0100 or ISA NCAC 02C•.0200 F7ezl Construction Standmdr and that a
Ifthis is a repair ftll out known well construction idformation and explain the nature ofthe copy ofthii record has beenprovided to the well owner.
repair under#21 remarks section or on the back of 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 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: `� SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 7_0 0 (t) 24a.For All WeIIs: Submit this form within 30 days of completion of well
For multiple wells list all depths li'dierew(example-3(200'and 2@ 100) 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 24b.For Infection Wells: In addition to sending the foul to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: L� construction to the following:
(Le.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test air pressure 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of`Environmental Quality-Division ofWater Resources' I Revised222-2016