GW1--04709_Well Construction - GW1_20240812

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WELL CONSTRUCTION RIIcoIRU-(Gl%`_i fortnterne(()k ditty
L Weil C aramelot IDinnnation:
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NC Well Contractor Cc:MRa•ion Nn•rder 1!.(till ER CASING) far manfturd milt)1tR LiNPR(If appllraMe)
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Morgan Well&Pump, INC rnr ii.i TIti nhiI+i�tn _
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(r)1>!I/ ]Ueli - 0 1 FROM 70____ DWML1 I! elite KI(M9 MAtPP(AI-
2.11'df Constrnction retail : L ll I. A. t..
Litre;wheal'',able well coumwoon pmnnta(1 a 11C,Ce,mM.Stttr.1'mranr..eft") _ _ ..
R. R. la
3.Well Use(cheek well use):
17.SCREEN
Water Supply Well: FROM TO DIAMK(�ER 'SLOTSI=_ T fCNLSa.
K __ .MATLR(Af• ..
0Agncuitural °Municipal/Public ft, n. in. _
°Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) R a. n. l — +, _ _
Q(ndustiavCo nmercial I.J Residential Water Supply(shared) ta.GROifr _
I1Imeanon FROM TO MATERIAL EMPLaCDt eTMF.l710D!N,OGTff_
Non-Water Supply Well: 0 R 20 R bentorJta __ paned r ____
°Mai itoring ©Recovery n. rt. '
Injection Well: n- rt.
°Aquifer Recharge °GroundwaterRemediation
19.SAND/GRAVEL PACK ll'aPpUtable) _
°Aquifer Storage and Recovery °Salinity Barrier FltOM TO MATERIAL GRLACT2tfu'1TMETfIOD
°.Aquifer Test °Stormwater Drainage n. n.
()Experimental Technology °Subsidence Control n. ft. .
13 Geothermal(Closed Loop) °Tracer 20.DRILLING LOG fetich additional sheetsifrucesury)
FROM TO DESCRIPTION(Tier,hardness,seNaark type,rain she.do.)
°Geothermal(Heating/Cooling
Return) then(explain under#21 Remarks) ^ rt. �v y
// ! (J rt. ft 1i +
4.Date li'ell(s)Completed: Well mf
5a.Well ocatioonn: ft r
Fa_-ihty'Ow Facility and(ifappl,abk) n• 2 r•` ` .. ( ;a
Physical Address, I 20?4,City,and Zip/ :.. ...e{I 1.-/1., I'll_ ECRKs'-.-.:..''-.. _ .
. _ . . -Jti; 'f
County Parcel Identification No.(PIN) t/tit,,;St-.3
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wellfield,one 1st/long' sufficient) 22.Certill 'on:
35. 5 ' I i� N gl. 7) ! W '- Z)
6.Is(are)the well(s)E)Permanent or °Temporary Sigoarareo fledWeU tractor Date
By signing this form,I hereby cetti that the,all(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or jNo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
gait is a repair..B out buts.,well construction information and explain(he nature of Me copy of this record has been provided to the well owner.
repai under till 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
constriction,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: 20 (it.) 241.For All Wells: Submit this form within 30 days of completion of well
For multiple wells lint all depths if different(example-3@,2000'and 2Qn 100') cons Wction to the following:
10.Static water level below top of cuing: 7 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring.we"+•' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) • 24h.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:
(n.e tugs,rotary,cable,direct posh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Z Method of test: eir 24c.For%Voter 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: p.r�J..:ed d�kavu: Amount: In • J 0( completion of well construction to the county health depanment of the county
where constructed.
Form GW.I North Carolina Department of Environmental Quality-Divbion of Water Resources Revised 2-22.2D16