GW1-2021-01574_Well Construction - GW1_20210309

vtt,D,IUL(L UNSTRUCTI 1�T lGt tC® UgHza
L Well Contmaot-Infa mation: For Internal Use Only ..... .
Chris Morgan
Noll Contmcror Nnme 14.IVA NES
3572 FRObI R. TO DESCRIPTIOiY
tt.
NC Nell Contractor Certification Number ft
iw
Morgan Well& Pump, Inc. Is.OIIT Eft CAS INOttormutti-casedtiveIIs OR(Rohr TO DIAIt[ETER LIVER rn ttcablc
Company Name [ (� THtc[CNESs MATERIAL
V 1 +, ft. rt. 6,19 in.
Z.VVetl'Construction Pe t6.INNER sd21 pyc
emit#: CASING OR TUBING(eothe"rmai closed-lot
List all applicable t"ell cOnsirliction Pen;r(i.e Vic couni. Siam.i'aroncG ett~) Moat TO
DfgdIETER THICKNESS 17ATL•RLU,
3•Well Use(checli well use): n' ft. in.
Water Supply well: ft. ft. In.
Agricultural 17.SCREEN
gesnid
uicipallPublie OM TOSLOTS[ZEQeothermat(Hcatine/Cooling Supply) ential Water Su l 'sin le M ft. to TH[c[rnEss atATERtAt
industrial/Commercial �:—•�` pp y( g ) ft.
t_.PResidential Water Supply(shared) ft. in.
Inigation IS.GROUT.
N0113,Wnter Supply Well.. rRonl TO
itfATERFAL EM1IPLACEnILiVT I MEHOD&AntOMT
` MonitoringI- o ft. � fr.
Injection Welh DRecovcry bentonite poured
ft, ft.
tAquifer Recharge
(Aquifer Storage and Recovery013roundwater Remediation ft. ft.
QlSalinityBarrier 19-SAND/GRAvELpACIC If iiwblc)
Aquifer Test enons TO
�IStotmwaterDminage M1[ATER[A[
HExperimental Technology ft. ft. EntPIACEniEN7ntETHOD
Geothermal(Closed Loop) C31Subsidence Control
ft. ft
Gcothcmtai(13eating/COoling Return �ITtacer 20.D
RIIS.iNG LOG(attach additional sheets If nemssary)
Other(explain under 2I Remarks) FRO}I To DESCRt 1ti color.hardacss,solltrorlt it 0. ,4.Date Welt(s)Completed: i2/41 Well LDI;`tl/8 ft J ft.
ALW Miss sier etas
5a•Well Location: 0 it. ft.
(� t 01 s ft. ft.
n/a r
Fociliry/ownurNamc ft.
Z � FacilirylDR{ifapplipble) ft.
o eser
Phy.' ]Ad dn ss,City.and Zip �� 4 ^S ft.
ft.
OW 04% rt:
County 101 21.REneA IC—S
Parecl IdcntiRcation i`to.(PiIV)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Prinr Unit
(if well Field no InUlOn&is sufficient) �WR Section
22.Certification:
�p W � Z /
6.Is(are)the wefl(s)OPetTnanent or 3'cm o
p racy Signature of CergfjEd)Nell ContactorG
7.Is G' F____
this a repair to an existin well: B��signing this,fomr.I herebp cert&dial die ssell(s)was(were)cwrnreted in accordance
jthis is a repair,fell our knouts tvc11 constarctioinformation anti etplail,die xatrrre of,he roPS'altlur-cord has been or 15A provided m Cc well 20o
repair under�31 remarl� C.0_00 Well Consiniction Slandae&anti that a
section or on the back oJ'thitforni.
S.p'or Geoprobe/DI T or Closed-L 23.Site diagram or additional well details-
construction. top Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
led:- only 1 G�i�-1 is needed. Indicate TOTAL conslruetion details. You may also attach additional pages if necessary.
drilled: t NUMBE g the sos
9.Total well depth below land surface:_ ( S UBAUTj Ate'MSTRGCi3ONS
l or ninitiple cells list all deprits ijdperem(etnniple-3Q200 and 2 a 00 j O 24a. For All 1�'eDs: Submit this form within 30 days of completion of well
10.Static Seater level below top of casing. canstmctioa to the following:
ljtvater level is above casing.use '+^ (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,PIC 27699-1617
Cn.)
24b.Eai;Infection J'Velis: 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 ATIKLLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,12aleigh,NC 27699-1636
23a.Yield(gp[u) Method of test air pressure
lac.For stater Sunaly d:'sniection Wells: In addition to sending the form to
I3b.Disinfection type: granular the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form ml-i North Carolina Dcpmunent of Environmental Quality-Division oflvater Resources
Revised 2-22-2016