GW1-2021-01511_Well Construction - GW1_20210309

=.Well Contractor For Internal Use Onl ......IDfortnDtion: y: _.......
Chris Morgan RECEIVED
Nell Contractor Name 14: TEI220NES
3572 M rRoni To DES ON
\C 1Yeil COntmetorCertlfiCadon Number Information Processing Unit
ft.
Morgan Well& PureWR Section fL R.
Co
l7, Inc.lnC I5. CAsI G r mots cased iveUs OR
mpany Name FROM TO MUTE TER LII�ERcrra llcablo
+1 (t, I�CKNESS MATERIAL
2.Wall'Construction Permit#: e i— 'S rr. 61/9 1°' sd2l
I Z-2(��Q Ct i•GQ,j J 16.INNER CASING OR TUBING(eotherntel closed-too pvc List all app!lcahle urllwnsrnretionpennirs(i.G UIC,Catngt:State Yarlanc�etc) pR01t
10 DIghIEi GR THICIfNESS
3.Weil Use(check-Well use): R ft ;a '1U1TER2'1i
Water Supply Well: ft. ft to
Agricultural 17.SCREEN'
Gcothctmal(HcaCmL►/Coolin oMunicipal/Public Oht TO '
g Supply) Residential Water 5u i rL D1ADiETER sLOTsizE TxtCB71'ESS htATER1AL
industrial/Commercial 1p'
PP Y(single)
DResidential Water Su 1 shared) ft ft. In.
htigatioD PP Y
PJon-;!' ;r Su pp ly Well.. Ill.GROUT
FRONT TO ATERLIL.
• tl4onitorind ''�1, 0 ft• 2D ft 11 EhIPLACEt14fiN•rp117HOa&AnlotmT
Injection lhrelL• QlRecovery bentanite poured
Aquifer Recharge t- ft R•
DAquifer Storage and'Recovery Remediation ft. ft
S Recovery ElSalinity Barrier 19 SAND/GRp
Aquifer Test FRONT Tl'1rI.PACIC ifs ilcablc). "
Experimental Technology 0Stormw2terDrainage ft. R. DtATERrAL en,rL,cts,E,tt alerHon Geothermal(Closed Loop) QlSubsidence Control
QlTracer ft' ft-
Ctrothcrnla!(Heating/Co0 Ing Return ''0 D1tILLING LOG(attach additional sheets If access
Other(explain under;r21 Remarks) �O1f To
r l /0 1 DESCR111rtON color,harda
4.Date lk ell(s)Completed: G{ 1 11+' O•ft. ft ess sdvroetr t c cram s'ag ere)
We01D>:n/a 1
Sj�Wcll Location: ft. ft.
IIffft ft.
Faoillry/Otvna n/a ft ft.
�f`►2 � �' Facility TDm(iFapplicable) ft.
Ph at Address,City,and Zip �g&o ft. ft.
R.
n!a a1.1�>Y R.
County ARIt3
Parcel Sb.Latitude and longitude is degreeslmiid e t
n cntificationNo_(piAi) i''tutes/seconds ��
(ifwell field,one tat/long is sufficient) or decimal degrees:
22.Certification:
i,
6.IS(are)tile lrel!(S)OPermaaent . A5 �-- 2aq �
Or QI�'emporary Signature orcertiiElWcn Contractor
7•hi this a repair to as Bp signing this fonu.I hamby ceraJ,that the urll(s)iv= were D
existing tivell: 017(cs or No Ithis is a repair,fill out bnouyr well consdnrctian infontmtinn and etpfaio the nnnrrn oftha mPJ'ofrhir recordha.been provided A to the well aumer. ( /col"'S11rad in aund Mar
a
uvllr 1SA AIC•IC 02C.0100 or 13.9 NCiIC O3C.020D Well Conre)cons S/wrd in a and der a
repair adder t:21 remarks seclion or oil Me back of thisfonu.
8•�'or Ceoprobe/DPP or Closed-LOOPGeothermal Wells havingthe same You
Site diagram use the back:of this page to provide additional well site details or well
construction,only I GW--I is needed. Idicate TOTAL, construction relict You moa III well dettuis;
drilled: n NUMBER of wells )also attach,additional pages if necessary.
9.Total Ivell depth beloW land surface: (� SL�i�'iTtAL 711STRUC3IONS
rror nu'lliple wells list all depAr iJdlGet ere(erampli 3 r@i 200'and 3e100) 24n-For All Wells: Submit this form within 30 days Of completion of well
10.Static crater level below top Of casing: 35 construction to the following:
!J'rttner level is above casing,rise Division of Water Resources,Information Processing 11.Borehole diameter: 6 1617 Mail Service Center Unit;
,Raleigh,r1C 2769 ssing ssing CID.)
rOtB 24b-For IDtection Wells; In addition to sending the form to the address in 24A
12.Welt construction method: rY above,also submit one co of this form within 30 days
(i.e.auger,rotary,cable,direct push,etc.) construction to the fbilowin Y of completion of well
FOR WATER SUPPLY WELLS OAILy: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i3a.Yield(;ptn) Method of test: air pressure
24e For Water Suonly&Iniection We11s: In addition to sending the form to
13b.Disinfection trpe: granular the addresses) above, also su
Amount: completion bmit one copy of this form within 30 days of
well construction to the county health department of the county
Fon»G�V-! where constructed.lVottb Carolina D epartmcnt of Environmental Quality-Division of 1Vater Resoumas
Revised 2-22 2016