GW1-2022-07364_Well Construction - GW1_20220808

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NC Well Contractor Certification Natabet
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Morgan Well &Pump, Inc. DIAMETER , TRICmMkIC WATERTA
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2.Well Construction P"t w: A11A FROM TO DIAMETER TMCENUS MATERIAL'
List all applicable Well construction permits'( _ffa Counts State,TVariance, IL ft. in.
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ft in.
3.Well Use(check well use): ft
Water Supply Well: I 11-SCRRUT. •VI FROM I DIAMETER'I SLOT
PAgdcultural omimicipwPublic, ft ft. in.
Geothermal(Heatiag/Cooling Supply) DResidential Water Supply(single,) R ft m-
I�dmrs ercial J Residential Water Supply(shared)
laigation I FROM I TO MATERIAL I EMYLJ& METHOD&AMODNT
Non-Water Supply Well: 0 ft- 20 ft b.ionite- poured
Monitoring DRecovery 11 ft.
Injection.Well. fL
Aquifer Recharge E3GroundwatrrRemediation
Aquifer Storage and Recovery DSalinityBarder I MATTMTAT. NIMOD
N 0 A,
ft
Aquifer Test Stotrawater Drainage
jlExperimental Technology 13Subsidencr Control ft ft.Geothermal
Geothermal(Closed Loop) Tracer
Geothermal
I'FROM To DESCRIPTION(color,hardness soil/mcktype,gr=size,ern)
Geothermal(Heating/Cooling Retim) 0 Other(explain under#21 Remarks) It ft A I IA--
4.Date Well(s)Completed: [21 Well JD#
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52.'Weli oration: ft ft1SftU%M
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Facilit3#0wner Name Facility ID#(If applicable) ft. ft. 4N IZ V4
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ft ft
,Pi9sical Address andZi ft. ft.
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CountyParcelIden cationNo.OM�D
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5b.Latitude and longitade.in degTees/minutes/seronds or decimal degrees:
(dwell field,one lat7ong is sufficient) 10 2 cation-
N T[ Is W
6.Is(are)the well(s) Permanent or OTemporary Smining
igpna rc Tf , ed Well Contractor
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B .- is form,I hereby certify that the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: L71 Yes or INNO W 15A C 02C.0100 or 15A JVCAC 02C-.0200 ppeg Construction Standards and that a
If this is a repair fill out known WeR COWDIX n information and explain the natw-a of the copy of this record has been provided to the well awner.
repair under 421 renuzrky section or on the bark of this 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 I GW-1 is rieeded. Indicate TOTAL NUhIBER'of wells construction details. You may also attach h additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells List all depths ifdifferew(example-3@200'and 2@10D) construction to the.following.
10.Static water level below top of casing: Unit,
(ft) Division of Water Resources;Information Processing
fwater level is above casing;use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Well In addition to sending the form to the address in 24a
U Well construction method: above,also submit one copy of this form within 30 days of completion of well
(Le auger;rotary,cable,tibrectpusi-4 etc,) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS-ONLY: 1636 Mail Service Center?Raleigh,NC 27699-1636
132.Yield(gpm) k21 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 Amount: I DZ� completion of well construction to the county health department of the county
where construbted.
Form GW_I North Carolina Department of Environmental Quality-Division of'Water Resources Revised 2222016