GW1--06488_Well Construction - GW1_20241104

1.Well Contractor Infoxmati.oa: • I • I l
Garrett Clause a::Y` fir- :" 'F l liga i > g .
Pltora To DESCRIPTION I
Well Contractor Name „ PA b f. 0`\ ft.
4550-A -fib ft. �.,k ft.'
NCWellContract=CertificationNumbDr ab:00 MaGi(for"mil"i c�rgaiellslirata1gRiifta:.lir64)21 u ,«!�'c :: •
Morgan Well&Purnp,INC PROM TO pTAMF.TER 'Z (NESS MATERIAL .
jG ft • ft a \!a in. S PV1'` V V C
CompauNeme 1� 1'Z I vG` #C G 01i,' B.z eotSer�ial;c)osedl'-.•pb .'2= 5; -a:ri-? rt ,:c `
PROM TO DIMMER TH ictasS MATERIAL •
2.Well Construction Permit#: ft. ft. In. ' ' •
List all applicable well constructionpennits(t:e.UIC,County,State,Variance,eta)
ft ft: in.
3.Well Ilse(check Well use): r,_ - _�_ ?u-e n:.v-.r
`tG�2TZlrC�s c; '�� €1t ic� � i ���t. _ �t'u .
Water Supply Well: PROM TO DIAMETER stow MO Tfficsrt>ss MATERIAL
I •cnitmal �viimiripal/Public ft fb m.
i Geothermal(Heating/Cooling Supply) laIResidential Water Supply(ogle) ft, ft.
Industrial/Commercial DIIResidential Water supply(hared) n$_ .- - - f$ =-S" .�r=•ti�:,all:?'`-
IIIigatiDIl FROM TO MATERIAL EMPLACEMENT ROD&AMOUNT
.ft ft ^ I�-C �U���
T
PTon-Water Supply Well: f ce
IMonitoring alb eovery ft ft.
Injection Well: ft. ft
=1 Aquifer Recharge 10CnotmdwaterRemediation ;'ty3„� `�r=v t
e 03.M.ADXMVSOPX•Glrti'fli eIiI;e)N7v'sRK_: k.A:.- ,00, L, :
Aquifer Storage and Recovery . 0 Sahmty.Bampr PROM TO 1VIA13RTAr. MPLACZYLENTMETHOD
• Test 0 Stormwater Drainage ft f. .
/
I Subsidence Control f£ ft
J Experimental Technology •
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5�
`.y03=EgCX'.Mtgar lr—. illi; fkl ec`essa>tip)-€ a, r..--gt- i-� Si
Geothermal(Closed Loop) ® R•0
ITra°er FROM TO DESCRIET(ON Ceder,hardness,soiUmektppe,grain size,eta)
U Geothermal(Heating/CpolingRetulm)) //BOther(explain nnder421 Remarks) •
G ft. ft b�r�Y!
Completed:. 6'6b-Ot-I Well ID# 5. ft Zv ft t(,tk �', L
4.Date Well(s)Compl � � flk rr 11
ft "l� ft' (J(r1/T
Sa Welll,ocation: n • ti Si j to a (_ . -• : _.
V9 n Il`/Qn((c�� c `n� Jr�� t'v tL ''' i
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Facility/ownerName Facility-DV(if applicable) (DO ft 1 4O ft. 5r� 5ran ' - , " "'
AO"K )c no.(estiIl�- �v ft. lt) ft m�,,N-e, 5i Ce. NOV 6 4 2024
ft 500 ft 0 ,ff A-- g(c!I' - I r,.`;,:.;-1 ?
PhysicalAddmss,City,and Zip VC) VIA t ,'��..—--�_i . tizikr3 > 3 _�12...-5 , '^ ui,:1
126
t�?I 7Zm11 ZL: 5s' ?= .v nc 3a� .i v#so=~c 2
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mmutes/seconds or deri•mal degrees:
(ifwellfreld,one lat/longissufficient) 22.Certification: ' •
-
'35.6 vSrs N g50,-73gZ0 ' W Oc-61)d- (6 2meuk
• • Signature of Certified Well Contractor Data
• 6.Is(are)the well(s)(d''ornament or DTemporary -
By signing this form,I hereby certify that the well fs)was(were)constructed in accordance
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7.Is this a repair to an existing well: Yes or No with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and erplaia the nature of the copy of this record has been provided to the well owner.
repairunder#ZI remarks section or on the back of this farm.
23.Site diagram or additional well details:j
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
constmctioD,only 1 GW 1 is needed.Indicate TOTAL NUMBER dwells
construction deiailR. You may also attach additional pages ifnecessaiy
drilled: 5 U.I31VIlTTAL INSTRUCTIONS
9.Totalwell depth below land surface: cv V (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Far 10.Static water level below fop of casing: vmuItple wells list all depths ifdi�erent(eswnple-3@Z00'ond,�2``@I00� construction to the following.
(fi) Division of Water Resources,Information Processing Unit •
Ifwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
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11.Borehole diameter: 0( ) 24b.For Injection Wells: In addition to sending the form to the address in 24a
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u`T J T r •above,also submit one copy of thus form within 30 days of completion of well
12.Well construction method: l`� � construction to the following: I •
(ie,auger,rotary,cable;direct push,etc.) ,
• Division of Water Resources,Underground Inj ection Control Program, •
FOR WATER S UkPLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) c ' Method oftest:4C �7^ •i '15a'lc— 24c.For Water Supply&Injection Wells:j In addition to sending the foam to
the address(es) above, also submit one copy of this foam within 30 days of
13b.Disinfection type:l.'ltC�i n���C Amount l.t. V completion-of Well construction to the countyhealth department of the county
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where constructed. - t
PornOW--1 North Carolina Department ofEnvironmental Quality-Division ofWeterRP...WM es Revised2-22-20I6
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