GW1-2021-01577_Well Construction - GW1_20210309

For Intemal Use I. Well ContractorInformatfon:
Chris Morgan
well Contractor Name 14:11% ZONES
3572 FROM TO DESCRIMOtIN
JrZd ft• zJ/ ft.
NC tVell Contractor Certification Number ft.
n.
Morgan Well 8-- Pump,inc. ts.OUTER CASING(for multi-cased ttella)OR LINER(ifn Ilcabla
Company Nante IRoar To D[ApTETER
t1 ft. ft MCIQJE$g bATERIAL
2.Well•Construction permit m; � S 6118 '° sdr21
ASING OR Mill G( eothermal closed-loo pvc
16.INNER C
List all apPllcaG(e uell coustrxction penaity(1,�U1C,Cowart:Safe,11�ariance•etc f FRONT TO
DL1p[ETER THICKNESS
3,Well Use(checliivell use): ft. fr. ;n, f11ATEniL
Water Supply I Well: ft' ft• io.
OAgricultural 17.SCREEN
r-yMunicipal/Public FROn1 TO DtaatErER QGcothcrmal(Heatingn;Aoling rL SLors[zE zxrc[rnEss NATERIAL
Supply) Wesidential Water Supply(single) ft. in.
�]lindustrial/Commercial l It.
QlResidential WaterSupply(shared) ft•
hligation I0.GROUT
Non-Water Supply Well: 18.G To
i17ATERLU. E1tPLACES=NTMMIOD&ANIDUN-r
Monitoring t- a ft. 2a ft.
Injection Well: ORecovcry hentonite poured
ft.
Aquifer Recharge rt.
oGroundwaterRemediation ft ft.
(Aquifer Storage and Recovery OlSaliniry Barrier 19 SAND/GRAVEL PACK ifa licable)
Aquifer Test FRONT ft ro
[]1Stormwater Drainage MATERIAL PN1PLACFaT£NT arFTHOD
Experimental Technology ft.
Geothermal(Closed Loop) DSubsidence Control
Ft. ft.
QlTracer
Geothermal(Heating/Cooling Return 20•DRILLING LOG(attach addonal sheets ii netessary)
Other(explain under 021 Remarks) FRoitil To DFSCR[PTION(color,hardness,soiarod;t c ecr;a sac etc.)
4.Hate Well(s)Completed• ��j�Z 1 , n/a d ft. (tj ft.
'� Vt ell Ill r I �C b��
Sa.Well L / Is- it. I '�/rrL+n Z2
anon:
��-4�_ nilft.
Faciliry/Otvncr i`(amc ft.
11,111,' Facility ID
(if applicable) ft. I ft.
V G t —D C '4 C7 fv f/e ft.
Physical address,Ciq•,and Zip ft.
(`� n. ft.
County ��� 0 -z 21.REilMj S
PaicclldiamificationNo.(Pti\� MAY 8 p 2021
Sb.Latitude and longitude in degrees/minutes/seconds
(ifwell field,one lat/long is sufficient) or decimal degrees:
22.Cerbnelltion: ( L'
N —W0 ,15U763 I «, f, DWR Section
6.Is(arc)the wcll(s) pe i'f�+ �l�f`.)
rmancut or T ' —' -��
QI_emporary StMatum ofCe"i Ed hell Contractor
7.is this a repair to an existing well: INo G/ Date
Ij1Gis"'a repair,fill Dift A-flaIvo we11 constructioni forinarian and Lt]11Q1n r11L'aatfrrB Ojrhe oPh 5,1 isrrccord Gar been provided to t/eritcll rrrhe �nsaruas(Noel corurrncred in accordance
uilG 15:1 A'C.dC 0?C.O100 or 13a ArGIC A3C.0200 well Coarnrrctiun Sratrtlardr and dial a
repair furder R?I remark section arc on die Lacl.ojdr (ornf.
S.For Geaprobe/BI'T or Closed-L 23.Site diagram or additional well details:
oop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l GRL 1Lis needed. Indicate TOTAL 1\TIJ ER of wells
drilled: r construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: STJBMai-TTAL LR'STRUCT IONS
ror rnnitiple wells list all depths ijdLererrt(ernmple-3 t 3 (�`')
t?i O'arrd_�a l00') 24a. For All Wells* Submit this form within 30 days of completion of well
10.Static hater level below top of casino: �(j construction to the following':
(later level is above casing,rise r^ (ft.) Division of Water Resources,Information Processing Unit,
I1.Borehole diameter' 1617 Nrlail Service Center,Raleigh,NC 27699-1617
Cn•)
rota 24b.For rniection Wells: In addition to sending the form to the address in 24a
12.Well construction method. ry 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 ti`AT LR SUPPLy WRELLS ONLY: Division of Walter Resources,Underground injection Control Program
132.Yield(0m) �0 1636 N-sail Service Center,Raleigh,IVC 27699_163G b r
Method of test: air pressure
24c.For Water SuDDIv&Injection,A,elIs: In addition to sending the form to
Amount:
136.Disinfection type. granular /� 07 the addresses) above, also submit one copy of this form within 30 days of
- completion of well construction to the county heal department of the county
where constructed.
torn OW-1
North Carolina Department of Environmental Quality-Division oflvatcr Resources
Revised 2-22-3016