GW1-2021-00590_Well Construction - GW1_20210205

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-1 For internal Use only.1.tYeIlContractorirt'ormatan: -- -
Chris Morgan
Well Cunlmcmr Name ]4.WATER ZONES
3572 e1OMI TO nFsctdPfloN
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NC Well Conaador Certificadon Number R
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Morgan Well&. Pump, Inc. If.OUTER CASING or muldaud+m➢s OR LWHR
Company Name PROMf TO DWIETER �mU
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2.Well Construction Permit d; W 6]m in. sd2t
'� ��� [P20— q13 go �Ro67N C INGORTU@INC ovc
Grr all applicable trail rnurrnrcvlan TO ( eatharnml Closed-loo
prrmirt fi.eU/C,Camrrr.Slater.t'artnn DIAMETER •ry;ClWESs
3•Well Use(cheep well use): cc eIe) «, ft. aLVEwaL
is
Wamr Supply WcU: ft. IL m.
Agticulmral I17.SCREEN
MunicipaUPublic FRont Tp
Grntharmal(tica[mg/Cooling Supply) R ft. !rt'� aLOTSIZe THIL'm�'iS.S MLITERIAL
�IResidential Water Supply(single)Industrial/Commercial (r•
QlResidential Water supply(she 2 Ia
LIi te MGROUT
Non•WaterSupply Well• FROM TO
MtATERLtL EntrL.uEMtenT mErnoo cr Anloun-r
Monitoring a a aO R.
Injection We Recovery hantonita poured
Aquiferft ft.Recharge Aquifer Storage DGmundwatttr Remediation R. R.
g and Recovery Dsaliniry Barrier 119R�ANDlCRAVEI,PACK ffa Ileablc)'
Aquifer Test TO MATERIAL
Q1StortnwaterDminage R• F.M1rWeFNEM'a{ETnpD
Experimental Technology R.
Geothermal(Closed LOop) DSubsidence Control
I. [r.
QlTracer
Gmthcmtal(Heatill coolingRe 2a'DRff-1•tNT LOG(Otto additional sheets lrneces5
Return) ' . Other(explain upder till Remarks} m°af T° DFscRI oN omnnaraam,smurodrn a orac Bret
4.Date Well(s)Completed:Jd'irt p IllWell ru Na G R. Er. '�d.—
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So.Well Location: ft,�—'-
R. rO G'w UC
Al sC4 ' U v R.
Facihry/Otmcr Namc
7,15
qq ee II Facility JD#"(ifappliwr bl) ft 2
rhYsical Address,�JZ ndC��rtC Lti S O'0dts !tej ft. ft.
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If 4kr,��,y ft R.
Conmy rde y40-7J7.46(6gp 21.REIV/AR1(S
Poicel ldm{i8ceitoa No.(PIN}
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcl Field.am laorum issuflieicu) [�
5-9254r N ��0 1 O62Z 22.Cerdficatioo:
W _
6.Is(are)the weU(s) )f Permanent or l--1, III 1 �( �� 26 2 /
t�}�Temporary 5 grata f"Itl9led Well Contractor 1
yy Dale
7.Is[his a repaU to an avidir. yv L—�, BJ rlgnfng rbtr)omr.(bereb:
I Ibir is v g well. LJ'Yes or QNo J carrjy tbat rhe.020 r)won(<rere)canrr u ted in aecanlance
f repaigff/ma inmrnwd/cmurna:wInfannalfwu and eip(a/n the nature aftba cPJ'ofllt(r rr ordth¢rba�pra rd�ot CO2elfoovre�f(Corte(na;rimr Smralardr and rbato
rnpa/rurtder.21 ramadY-when ar mr the back oflhb forni.
S.For CeoprobWDPT or Closed-Loop S 23.Site diagram or additional well derails:
Loo Geothermal Wells baying the same You may use the back of this page to provide additional well site derails or well
construction,only I GW41 is needed. Indicate TOTAL NUMBER Og�.Ogs Construction details. YOU may also attach additional Pages ifnecasary.
drilled: KE
9.Total well depth below land surface: /do O CEI�'A-L TNS— RUcno c
For rntrllfple,rel/r fisf al(deptlu lfdlderartr(emniple-3@n2p0'and?r@1001 A) 24a. For All Wets: Submit this form widen 30 days of completion of well
10.Smtic water level below ra ''
p of casing; `7Q A e/ P"ucuon m the following:
(!wafer(eml it above casing,use"a• �eSSln Division of Water Resources,Information Processing Unit,
11.Borehole diameter: �WR$6CeSl 9Unli 1617 Mail Service Center,Raleigh,NC 27699-1617
Ua') 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one co of this form within 30 do
0-C.auger,rotary,cable,direct push•eta) Construction to the followineY Ys of completion of well
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,INC 2769 9-1 63 6
13°'Yield(--pm) Method of rest. air pressure
24C-For Stater Suooh'&Injection Wells.
the addresses) above, also submit one copy of this Firmswithin 30 day
to
I3b.Disinfection type: Granular days
Amount:�() O2,
completion of well consnuction to the county health department of the count where constructed. .y
Form OW-1 North Carolina Do pomnenr ofEorironmenial Qualify_Division of Waicr Itesourna
Revised 2-2.1_2016