GW1-2021-01357_Well Construction - GW1_20210329

Wt g g,d:UNSTRUUTIOIV REd®RID G y .
For Internal Use Only.
1.Well Contractor Informntlon:
Chris Morgan
R'ell Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
3572 l: R.
NC WUI Contractor Certification Number fL ft.
Morgan Well & Pump, Inc, Is.OUTER CAETNG for mutti<osed welt. OR LINER eablay
FROM TO DL1nIETER TIED nATERIAL
CumPallY Namc +1 ff It. 6716 in. sd2t
36 33�3 pup
2.Well ConstructionPermit$: i6.INNER CASING OR TURrvs G( eothetmtal dpsed•tao
PROAI TO DL1n1ETER THICIWL56 n]ATERLIL
Lill oil nppl/cable a rfl cmirmrctian aennfts fi.e U/C,Cmra(c Slate,Variance.ery R. R, im
3.Well Use(check well use):
ft.
Witter Supply Well: 17.SCREEN -
AgriculttualMunicipaUPublic r•Rons To nunttTER scorslze rnfarn'Fss nLtTE
Goothotmal(Henting(C0o11n Supply) ft R. in.
g E§Residenfial Water Supply(single)
pllndustrial/Commercial it. ft.
QlResidenfial Water Supply(shared) 10 GROUT
1171 ation
Non-Water SuppivWell: moat To NATEliL1L CniPLAC&11ENTn]LTHOD&dn10UhT
Monitoring RCCOYCry ° f 1a f4 henlonde poured
Injection Well: R. R,
Aquifer Recharge Groundwater Remediation ft• R.
Aquifer Storage and Recovery Dsaliniry Barrier 19.SAND/GRAVEL PACT(iia Iiwble)
Aquifer Test FROM D TO MATERIAL
Sto1m]va R
terDminage . Ct rMrLAcnn]rnTNETxom
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) ITmwr ft rr
20.DRILLING LOG(attach additional sbeeb ff necessary)Gcothcmml(Heating/Cooling Return) Other(explain under r2l Remarks) FROM TO OE5CRIMON real.,hand, saiVmdtll esnms'aa star
q '1�-Z a ft. o R• b,� �-
d.Dule Well(s)Completed: J Well IDS Na .� ft. a ft. e�
5a-Well Location: Dro`'r^ b•.i�-
{� 3' ft. SS ft. SO C t hq c 4
f�✓J n/a ft. to it
racibry/Owncr Namc juP� I
I I FacilitylDg(ifapplicablc) ft. R,
Gof Z $rgUSh41, tt b A'l0 k Cn I/S ft. ft.
Physical Addn.ss,Cny,and Zip fr. fr.
—9 0 tJ CL/�- dr '�I I Q 14 6 ?l.REMARKS -
County Parcol Identification No.(PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laUlong is suffcicnQ '+J /ate ' .
3Se 6 )1 Ll SL1 �7S U .O p��660 32.Ccrflficati/o///a:
W i . /`,6 � r1
G.Is(are)the well(s) X Permanent or QlTempora T Stgnatum of lu E0"all Contmcmr ��� Z `
Dale
d)'signing tilts Jana,/homby cxr10 rbat the mell(sl tray(were/ennstnrcred in accordm¢c
7,Is this a repair to an existing]yell: Dyes or QNo n'ilb 15A NCiC 0]C.0/00 or 13:f A'CAC 07C.0200 Nell Canrtnrcriwi Standard,and that o
If this ienrepaigfill mu[nmrnmull construction information and espla/n rile nunire oflhe cape aftbls racordhas been prurided1.du,uxl!anmar.
repair under':?1 mmarir seclian art or.the Lack of dtis(om�. .
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal titells haviag the some You may use the back of this page to provide additional well site details or well
constmctioq only 1 GW- Is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional oases if necessary.
dNled:_
L /D SUBMiTTA L r_^IS T RUCTIONS
9. 'Otalul"well depth berme land surface: (Y) 24n. for All 1i'ells: Submit this (arm within 30 days of completion Of well
Pmvnultiple.re(Is list at(deptfa TfdLerem(crumple-S@200'atd o@1001 Y
construction to the following:
10.Static]eater level below,top of using: G (IL) Division of Water Resources,information Processing Unit,
f nn(er(ere(is n6me casing,nsc"+"
1617 Mall Service Center,Raleigh,NC 27699-1617
H.Borehole diameter: 6 (in.)) 24b.For infection Wells: 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,mlary,cable,direct push,ere.) construction to the f)llowing:
FOR WATER SUPPLY MT ULS ONLY: �—� Division of Water Resources,Underground injection Contra]Program,
Oi I636 Pitail Service Center,Raleigh,NC 27 69 9-1 63 6
13a.Yield(gpnU 'Method of test. air pressure 24e Fur:rater Suaviv E saicction Wells: In addition to sending the form to
granular �� the addresses) above, also submit one copy of this form within 30 days of
�q
136,Disinfection type: t3 Amount:---I--{=0— completion Of well construction to the county health department of the county
where constructed.
Fan»GIN-1 North Carolina Department of Envimamenul Quathy-Dwision atwmer rl.owes lkc ti cd 2-2::0 16