GW1-2021-01554_Well Construction - GW1_20210309

2•Nell Contractor IDformation: For Internal Use Only:
Chris Morgan :RECEIVED
Well Contractor Name
q
29:}VATERZO.tdES
3572 (1Ak K ZOZt r•ROIH TO DESCRIpTIO,\
3Zo fit. Zl ft.
NC Well Contractor Certificurian Number
Ir'[l?orrlation Processing Unit f1• rt.
Morgan Well& pulp
p, Inc. 6WR Section ts.ourERc
MOM ASIA G(for multi-cased tvelLs)OR LIN
Company Name TO DIAaiETER ER([fn ,cable)
/ +1 t[. TffiCt4YE5s ilfATERIAL
2.Well-Construction Per /�F/ �\ V ft. 61/8 in. sd21
List a/I npplicahle uel/constnrcNon w r O 03 16•INNER CASING OR TUBING Pvc
permits(i.e U/C Carrnp:State.Torrance,etcJ FROAT TO { eothermal dosed-loo
3.}Vell Use(checl:well use); DIAAlCrER THICKNESS n. fL in. 11ATE[tIAI.
Water Supply Well: fit.
fit• to.
Agricultural 17.SCREEN
Geo[hcnnal(Hcating/Coolin Su oMunicipal/Public rROYT TO DIANIMR
g Supply) ( (Residential Water Su j ft. SLOT SIZE THICIO�ESS 6%'Uk RIAL
�lindushial/Commercial ft. in.PP Y•(single)
brio DResidenfial Water Supply ft. ft•
anon pP y(shared) in.
Non-Water Supple Vdell: I0.GROUT
rRO,%i TO MATERIAL
Monitoring 0 ft. E1iPLACEniENTaIEiHODIc:�nlouvT
Injection L`Jell: Recovery zo fit' bentontle
ft. poured
,Aquifer Recharge ft.
QAquifer Storage and Recovery Groundwater Remediation ft. ft.
DAquifer Test OSaliniry Barrier 19.SAND/GRAVEL PACI( -fa Hcable)
FROMTO
Experimental Technology QlStormtvater Drainage fit NIATERTAL. rr EAtrLAcr•.nlEn r drF.THom
Geothermal(Closed Loop) ISubsidence Control
QlTracer ff ft.
Ccothemmal(Heating/Cooling Return) '0
Other(explain under rr21 Remarks DRILLING LOG(attach additional sheets if necessary)
FROM TO
DESCR[Pm t ti(cola,hardrim scillroclm ty S grain S40,etc.)
4.DateLVell(s)Completed:� y^�Z� fJ fe• fit.
-'�--�_ Well II3€n/a a D�„•j<-
§3.1�ell Location: fl ft.
• /0A / ft. 3bV ft. n
✓wiS L({ fi/a l� Vt � t
raciliry/OtvnerAlumc !Uv ft. 3 d it.
Fuci(itylDR{ifapplicable) ft. I — 4 '
L� �, �,+ fit.
physical Address,City.and Zip trOA S �A+'On ft. ft.
L.l^ C O 'A_ ft. ft.
Coumy 7�6 9 l 21.REMARI(s
Parcel Identification No.(PI1,r)
5b•Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvcll field,one lat/long is sufficient)
TV 7d f , Z 2. Certification:
6.ISOM)the tyell(s)•Y Permanent or ii----�),,T•em i / y
L!'' gorary St- ature ofcertlfj9d Well Contractor �Q� L! t�f LI 7,is this a repair to as existing well: Dyes BI signing rh/s tomr,I hereb Dale
Phis it a repair,f!!orrt 6notvn well construction i jonnatiau ant/evp/ain die nuurre ojthe coP2•ajdiir record has hero provided ra the u•
nillr I5,1 htC.•1C 03 2 cerr05,that the ttr//(s)uas(rverel corsrnrcred in acco,rlumce
repair under 411 renrarlts section or on the bath ojdiis(orn,. C.0100 or IS f NGIC 01
C.4100 F7e11 Conrtntctia,r Standards and that a
t//oumer.
l or Oeaprobe/DFT or Closed-hoop Geothermal bVeiis having 23.Site diagram
construction,only 1 G1to 1 is needed. tram or additional well details:
the same You may use the back of this page to provide additional well site details or well
drilled: t Indicate TOTAL�'U-�1BER of wells construction details. You may also attach additional Pages
9.Total tyell depth below land surface: 3 / v SUBTTA L fi+'STRUCT i01�'S p '� necessary.
/'ar•audliple tvcdS list ail depths jdgerent(eranrple-3 rt 300'and 1(�IDO� (f`) ''-4a• For All Ew'eDs:G/ --- Submit this form within 30 days of completion of well
10.Static Water level below,to U construction to the following:
ljttater level is above cosing,uSe•• of casing:
I.Borehole diameter: Division of Water Resources,information Processing unit,I Mail Service Center,Ralei h Al
(in.) 1617 g . C 27699-1617
I2.tVell construction method: rOfian/ 246.Ivor Infection We In addition to sending the form to the address in 24a
(.e auger,rota above,.also submit one copy of this form within 30 days of completion of well
rotary,cable,dirge[push,etc.) construction to the following:
FOR WATER SUPPLY Vi LLS ONar;': Division of Water Resources,Underground injection Control Program,
13a.Yield(gpn;) 1636 Mail Service Center,Raleigh,NC 27699-1636
I -I thod of test: air pressure
24c par:'eater Supply 4x Injection TNells: In addition to sending
I3b.Disinfection ti pe: granular O the address(es) above, also submit one co r:the form to
amorm
ount: completion of well construction to the county healhlsdepattrrm within
of 0 days of
Fonn tJA'-1 where constructed.
North Carolina Department of Environmental Quality-Division oflVaterResourccs
Revised 2-22-2016