GW1-2022-08475_Well Construction - GW1_20220907

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NC Well Contractor Certification Nnmbet 15:OUTER-•CASII�TG,(fo"r mnl6 eageH wells)bRLIII�C� licab]e',°::::•.• '"
Morgan Well & Pump, TERIAL
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Company Name 16 aII�ER CASING OE•TIIBII�G. eon2ermalclo'sbd3oo' '`��
TO DIIDA�T�R 1 TffiC14�S5 MATFi2TAT:
2.Wall Construction Permit#: I� ` � in.
List all applicable well construction permits'(f e.LUC,COJD*V State,Yariance,etc.)• R' ti I
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3.Well Use(check well use): ;:• `;.. ;. :;-;-::.;
Water Supply Well: 17.S
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.SLOT SIZE y TIiTCIO�SS TvfA1'ERIh7..
Agricultural mmunicipal/Public R ft 'n
i Geothermal(Heating/Cooling Supply) ®#Residential Water Supply(single) ft ft in.
I ercial J Residential Water Su ply( ed) - •r a.. '.:.;. •,:- .= `';':"= 'c
P star ::'18:GROUT-.".."_. =" .-'-' `- - _•.:; ..,•. ��... .. .,
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non FROM TO ,MATERML II�L4CE�NT.METHOD&AMOURT
ater Supply Well: o 20 bentonite• poured
oringRecovery fi tin.WeIl R ft
er Recharge �I GroundwaterRemediation ..79:SAND/l'I2AVEL'P6.CK if a"licabl'e ":.:>. �'::er Storage and Recovery �I#Salinity BawerMATFFLTAT FrYffLACE1urENiMETHOD
r Test �Stormwater Drainageft
mental Technology Subsidence Control
:20.tiR1LrSNGSOG'(�cidaftonalslieets�fneces "o!ermal(Closed Loop) �ITracer DE8CR-IPTroN(colorhmrdnew,soillrockY q siaetc)
FROM TOrmal(Heating/Cooliag Return) J Other(explain under#21 Remarks) Qj ft ft
4.Date Well(s)Completed.3 Well ID# ft 5rt tad If•
Well Lotion: 3s 5S ft k-
�Facmty/owner Name Facility ID#(if applicable) �� �� QY � INUAL
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P ical Addrrss,City,and Zip %GO `C
ba-S � 001
County 0.� Parcel Identification No.(PIN) Y7 ..... p (lit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(rl'well field,one]at(long is sufficient) 5.005A
cation:
. 5�4g5 N �.�S�� W
i ed Well Contractor ate
6.Is(are)the wells) Permanent or OTemporarp
isform,I het•eby rmtify that the wants)was(were)constructed in accordance
7.Is this a repair to an existingwell: QYes or VNo C 02C.0100 or 15A NCAC 02C.0200 YYeII Construction Standards and that a
IfflAr is a repafr,fill out known well construction information and exphrin the n-ure of the copy ofthis record has beat provided to the xzII owner.
repair under#21 remarks section or on the back of Misform. 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 construction details. You may also attach additional pages if necessary.
drilled: `� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _0 O (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdfferent(ermnple-3Q200'and 2(_00� construction to the following.
10.Static water level below top of casing: 4O (ft) Division of Water Resources,'Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (�•) 24b.For Injection 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: construction to the following.
(Le.auger,rotary,cable,directpusb,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 24G For plater Supply&Injection Wells: In addition to sending the fog o t
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.
Revised 2 22 2016
FormGW-1 Nortb Carolina Department ofEnvironmcntal Quality-Division of Water Resources