GW1-2022-08585_Well Construction - GW1_20220503

L Well Contractor-Information:
����CeTT CI�V 14:.WATERZONES
Well ContraC camme FROM TO DESCRIPTION
ft.
ft ft f
NC Well Contractor Certification Number
� '15:OIITER:GASING,(fnc multi=cased wells)OR T'Tnri?R if'a"licahle)'� `:::.:�'•.".:
Morgan Well &Pump, Inc. FROM TO' DIAMETER i TtucxvESS MATAx.
Corn am Name 0 ft 2 ft 61/61 tm• sdt21 pvc
P Y / // r� i
y Nvi u� b G `"I 16 IlVNER C4S]TiG OR•TI7BII�G: 'eotliermal closed loo .'.:`:.;' .; :'
2.Well Construction Permit#: l� FROM I TO. DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(ze IIIC,Cowtiv,State Ymiance,etc) fr- ft in;
3.Well Use(check well use): ft ft. in
Water Supply Well: 17_ -
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaYPublic ft, ft in,
Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft - ft in.
-Di Industrial/Commercial E3Residential Water Supply(shared)
i 1ni ation I FROM TO ,MATERIAL E111PI,ACEMENTMETHOD.&.-MOUNT
Non-Water Supply Well: p ft. 20 ft
bentnnite poured
[Aquifer
oring DRecovery ft ft.
Well:
r Recharge EI Groundwater Remediation ft ft
Storage and Recovery Salmi Baaier :�:SAND/GRAVEL'PA, ifal3' OM �TO MATERIAL EMPLACEMENT METHOD
r Test 0Stormwater Drainage ftmental Technology Subsidence Control ft ftrmal(Closed Loop) 1ITracer :20.3)RMLI IG.L'OG'(attich=additionals7ieetsifueces's-7.:5'rmal(Heating/Cooling Return FROM TO DESCRIPTION(color,hardness,soil/rock a in size,eta
�ea�� g ) J Other(explain under#21 Remarks) ft
4.Date WeIl(S)Completed: -`�17 Well ID# /J ft. -'o ft
5a.Well Location: 6 d
K A CAS- Ume� L L C 7 o ft ft
ility/OwnerNamee ` fi J
Facility M#(ifapplicable)
Facility/Owner
IL ft. ft
Pliysical Address,City,and Zip 2 // ft. ft
L,A CO{ti. q•J`'(�b 21:Itxnreuus - -:r' 11;
t :C
County Parcel IdentificationNo.(PINl MAY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY O 3 2022
(iffwweU field,one lat/logno is sufficient) 22.Certification
•N oil I bZ
6.Is(are)the well(s)J&ermanent or OTemporary Suture of Certified Well ntractor Date
By sio ung this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or iMNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Mell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and ecplain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarky 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 if necessary.
drilled:_- ' . 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (ft-) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells Est all depths ifdiierent(example-3@,200'a.d 22@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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
lI.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rOY L` above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.)
construction to the following:
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 Suuuly&Infection 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: Amount: 6 Z 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