GW1-2021-01565_Well Construction - GW1_20210309

nC®RD ��1 For Internal Use Only. ••
L Well Contractor information:
Chris Morgan
11'ell Contractor Name 14:1VATF,RZONES
3572 FROM TO DESCRtr JOIN
ft. ft.
NC Well Contractor Certification Number R.
it.
Morgan Well& PUMp, Inc. IS.OUTERCASING(for multi.casediveits ORLWEt2tifn itcable)
Company Name FROAI TO DWI
+1 rt. / (t T�CKNESS hfATERIAL
3 b 61/8 in. sdr21
Z.Well'Construction Permit#; �� ��g 7 pvc
List all applicable a ell canstnrct/on penaits(i.e.UlC,Cotten:State,{'ariance,eta) 1G INNER CASING OR TI1Bli1TG( eathermal dosed-lao
FR011i TO DL MIER THICKNESS
3,Well Use(checklveil use): rL fr. aiATERIaI,
in.
Water Supply Well: fI' R. to.
Agricultural 17.SCREEN
unicipal/Public FRONT TO DlAiliE[Eit SLOTSiZE TiftCiO�ESS MATERIAL
QGeathcrmat(tieating/CooliAg Supply) esidential Water Su 1 'sin a fL ft. ;n,
Industrial/Commercialn PP Y( � ) rt.
QlResidential Water Supply{shared) rI• in.
Irrigation lII.GROUT
Non-Water Supply Weil: FROM To
h1ATER41L EhtPLACENEAT hiLTHOD @ AAIOU',T
IMOnitonng 0 rL 20 ft.
Injection Well: DRecovery bentonile poured
ft. It.
Aquifer Recharge
01GroundwaterRemediation ft' ft. _IAquifer Storage and Recovery QlSalinity Barrier 19.SAND/GRAITL PACtC(ifa Iicable
` _ Aquifer Test FRONT TO Nil licaL QlStormwaterDrainage (t Ea1F-CMEN �iF.THOD
Experimental Technology rL
HGeothermal(Closed Loop) QlSubsidence Control
ft. ft.
Geothemial(Heating/Cooling Return �ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Other(explain under-621 Remarks) FROM TO DESCRiM iOti(color,hardaeu soiUrael:! a ec,io siz0.etc.)4.Duce Well(s)Completed: ���Z' rt/a v ft. O ft. rOLvn n; �.
Well M# 10 ft. 3u ft.
5a.Well Location:
I, i e 4 /�ek4 '�>, rt. o ft.
L n/a v fr. ft.
Faciliry/OwnorNamc ��^,�
n�� Facility IDR(i/fapplicable) ft. ft.
` S CO "« 'Df HLJA��/,�Vr 1 e ft. fL
Physical Address,City.and Zip
County 1.REMARKS
Parcel Identification Aio.(plNl Y
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suflicicnt) Information prQC@S51n Unit
6 13 Z 22.Certification: uclion
f W
fi.Is(arc)tttc well(s)
tn yPermancnt or DTemporary Signature of Cc]II i d hell Contractor v 1
G° Dole.
7.is this a repair to an existing well. [�IYes 0r hjo ay signing this form•I hereby'cert fi•that the tteA(s)vt=(were)co Doi e.red in accordance
TjUiis is a repai,;fill out taotvt,waft constntcrioe information and explain the nature of the c PP ofth(sr te�cord has been Or pr154d l C 0....
,e 1.0200
00eW Well Ca"I"Ictinn Standards and that o
repair under m21 rc,uarb section or on the bark of r1,&f0 ,.
S."'or Geoprobe/Dr-T or Closed-L 23.Site diagram or additional well details:
oop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 G��� is needed. Indicate TOTAL NU114gER of wells
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 166 sUBTTAL INSTRUCTIONS
I a,,,,,ltiple tte//s list all depots rjdderent(example-3 rt 200-and 2(a 10p� {��') 24a. For A ells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 3 V construction to the following.
lfuater level is abate cashg.use•+" (ft•) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Vail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Injection Weil- In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this form within 30 days Of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY w1rLLS UNLY• Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) V air pressure 1636 Mail Service Center,Raleigh,NC 27699-1636
iti?ethod of test: p 24c.For Water Suopiv&inlecton Wells: In addition to sending the form to
13b.Disinfection type: granular /' �- the address(es) above, also submit one copy of this form within 30 days of
Amount: h completion of well construction to the county health depa ent of the county
where constructed.
ronn GW-! \orth Carolina Department ofEnvimnmental Quality-Division or�yatcr Rcsaures
0 Revised 2-22-2016