GW1-2021-01329_Well Construction - GW1_20210329

For Internal Use Only.
L-shell ContractorllsIn n'tton:
Chris Morgan
Welt Contractor Name 14.IVATERZONES
FROM TO DESCRIPTION
3572 `/o R. it., R.
NC Well Conuactor Cenifieadon Number fL f6
Morgan Well & pump, inc. IS.OUTER CASING for mWti�eosed srcllr OR LINER rf
DIAaiE[ER cable
Cpmpally Name M1RON TO TmCf4YFSS bfniERNL
if ) +1 ft• ft. 61I8 in.
d �� G 7� salt pvc
2,"01,IPCunsMtell Permitd; FROM ER CASING ORTURING( eod rmai List n/(a FROM To atoned-Ioo ppse(Check
ck well
use): aenrtitr(i.a UIC.Cmrrnc Smle.l'ariaac-cclo fL pGaiETER THICIOV@SS p1d-rnRanh
3•iVdl Use(check well use): R.
Water SupplybVeh: fL R• lO.
77.SCREEN
Agricultural DMunicipal/Public roans To DIAb7ElER SLOTStZE
Geothermal(ficating/Cooling Su I IL M In, t m'E55 MATERIAL
PP Y) residential Water Supply(single)
�I Industrial/Commercial DResidential Water Su I ft ft. In.
Ira ation Supply(shared) 10.GROUT
NCR- ater Supply We11: r•Ront 'to M'iTERGL
ESIPLACEnmN r alMOD E AOIOIAT
\ianitoring ff''''��tt�� o R, 20 R.
tDRccovcry balance poured
Injection Wall: ft R
Aquifer Recharge
❑IAyuifer Storage and Recovery Groundwater Remediation ft.
ft.
Barrier 19.SAND/GRAVELPACICEfa livable
Aquifer Test FRO%{ TO MATE
Experimental Technology RGL
QlStormvreter Drainage R ft
. F.HPLACF.\IEM1T A{F-THOD
.
QISubsidence Control ft Geothermal(Closed Loop) fL
ITmcer nGcothcmhal(Heating/Cooling Return) 20.DRILLENG LOG(anach additional sheen ifnecessary)
Other(explain under T21 Remarks) FROM To
DESCRII'fit\(salo,hartlnet�soiVmtlat Cenln svc,del
Z�� o
4.Date Well(s)Completed: ft. R.— ell IDR n/a ar .
e•1
5a.W ft.ell Location: > O n. �4.1n
Faml!ry/Owner Namc /Cw• �'t�
Facility iD"(ifapplicable) ft. rt.
(270 (•<., n Scl s� .y ft.
PhYsicalAddress. -
ft. ft.
n0U 4n" - n1w s�s (S(z.. 21.REf✓ARI(S
Loamy
Parcel Idc¢dfica{ion No.(PM) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwcll field.anc IaVtong is sutHciem) I"
SS S2y740 -9o, ?S778. 17
--.Certification:: _ . .. .
rl W _
6.Is(are)tlrc weu(s).OPerma¢cnt or OTemporary !
S gnatum-i Ccnt lFd Well Conumctar
� Dale
7.Is this a repair to an existing well; IL-tI,' BY signing this Tom:,nrercbp[erlN rbat tire av:M sl vas w
"Pit isnrapai{fi/l'ul6mmde,a,Vil c,,Ila,back
infammnau mr❑il Crfroain the nuRrre oflhu cope oflbis�icro 02Cl 0100aru'dedm Geurl 02 0eWell Ce�rtrct�Smrrdnnicled rrd.,aad,he,rI,
repels under`.'Il rc/I-III o"71"ar'n(la•back'fllon"arm.
G.For GeoprobelDPT or Closed-s 23_Site diagram or additional well details:
�ooD Geothermal Wells having the some You may use the back Of this pave to provide additional well site delails or well
construction,only 1 GW-Isis needed. Indicate TOTAL NUMBER ofsvclls drilled: \ conswuion details- You may also Enoch additional pages if necessay.
9.Total well depth below land surface: r 6 V SLBM_ITTAL INS-,RUCT IONS
Pa"aalitp/aaa/b'list al/deprfv fd erenr(cram te- o (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
lfnurer lerrl a'bar"casing,ase"+" (ft.) Division of Win ter Resources,)
nformation Processing 11.Borehole diameter. 6
161?Mail Service Center,Raleigh,711C'_76 9-16?7 Unit,
(m) 24b.For injection Wells. In addition to sending the form to the address in 24a
72.Well construction method: rotary above, also submit form one copy Of this fo within 30 days of completion of well
(,i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR fir erER SUPPL y WLLLS 0N?,Y: Division of Water Resources.Underground injection Control Program,
/2 1636 Mail Service Center,Raleigh,INC 27699 1636
13a,field(gpnil I itiiethod of test. air pressure 2d
a Far ii'ater Sunph•E Infection-Wells: in addition to sending the form to
13b.Disinfection typo:Iranular s^0 the address(es) above, also submit one copy of this form within 30 days of
Amount: L completion of well construction to the county health department of the county
where constructed. -
North Carolina Depanmcm ofEoviroamanlzl Q-111y-DP.-istan arwnmr na.ov.c—
Revised 2-2-1-3016