GW1-2021-01331_Well Construction - GW1_20210329

ffi—LL d:UNSTRbUC' ION RAC®RIB
For Internal Use Only:
I.Well Contractor Information:
Chris Morgan Well Contractor Name 14.WATER ZONES
IROnt 70 DESLR1YIfON
3572 Zv rc.
NC Well Contractor Certification Number ft. ft.
Morgan Welt& Pump, Inc. Ta•ODT6R CASTNG(to, timsed wells OR LINER(I ncable)
FROM TO DIAniETER TmCCWESS nATERIAL
Cumpany Name .1 fl. G / R'I6.INNER CASING� 6118 in.S2 S5a v stl21 cave
?•Well Construction Permit": G ORT(JatNG( eothernml dosed-too
List ell aPpllcahle urll rnosmrdianpennitr(i.e.U/C,C,...�t,State,l'arinnca rteJ FROM CL T° DL1atEfER TttICIWGS6 MATEln L
Ft. n
3.Well Use(checli well use): ft
R Ia.
tauter Supply 4Yca: 17.SCREEN
DAgriculttual DMunicipal/Public Faont To DtAniE1ER scorstzE rRlctW nL) a
p'Gcmha[m g Supply) Water Supp
�int(13ea logtcoolin Su 1 f° a m
lndustriallCommemiol ly(single) It. R. in.
QlResidential Water Supply(shared)Iltia0.t10n 70.GROUT
Non•Wnter Supply Well: r•ROM Ta aIA7ERLIL Entl'wcantEnT mErnonmAmounT
\donitoring I-7� ft. beatitude poured
t IQection Weil:: QlRecovery rt
ft.
'Aquifer Recharge QlGroundwater Remediation it• R.
DAquifer Storage and Recovery QlSalinity Barrier I9.SAND/GRAVEL PACK;fa Itrnblc)
Aquifer Test FROM TO MATERIAL F.MPt.ACF.NEAT at ETHDn[]IStomtwaterDminage ft. FL
Experimental Technology
ISubsidence Control it tt
_
Geothermal(Closed Loop) ITracer
(—� 20.D1LR.LING LOG(attach additional sheets u necessary)I_{Gcothcmml(Heating/Cooling Return) Other(explain under;.2l Remarks) FROMTO DESCRIM0 colo,heNoess,solVm[I:h'aanlnsiu,ele)
n G ft. 6 FL l L lJ:d..We l Location:
Completed: •����Z� Well ID.Na 76 fl D. I ro4 ; rl�
Sa.Well Location: G ft. U fL
Llll.'Sa... :/� nla cart. 6 D. ;nlc.
Famhry/Owner Namc `yam'
Facility lDA(ifapplicable) it. Ft.
Sr4c)S�ka. nD oo✓C-s lit i[• ft.
Phrsiral ddan,Cep•.and Znp
A, •a� -L 12 p-2 Ct 21.NUM ARio
.
County Parcel ldentificationllo.(PIN) 1 ,
5b.Latitude and longitude in degrees/mloutes/seconds or decimal degrees:
01"Iell/field,one lot 10119 is sufficient)
3'• �I26•Lp :Z.Certification:
7 r;
I-. -I,
G.Is(are)the wcIl(s)XPerma¢c¢t or E3-fcmporary Srgnmum afCcm)Ed Mfdl Contractor Daly
7.Is this a repair to a¢ BJ,signing tbir faun,1 herebp rerr fi fimt die a»1((sJ leas(were)conrtmoed in accordance
p a-tilshng well; Yes or �I4o 011,15ANGIC 02C.0100 or 15d xlcic 02C.0200 Ne71 Covvns+imr 9audo,dv and dial o
/flbis it a repaiq fill out 6nmwr a»(1 consrrsution information unit explain the nature oflhe wpj'ofthis recardhas been pruvidodra the well nnmer.
repair under t.'21 remarks section oron the bath oftltir_rorn:.
23.Site diagram or additional well details:
G.For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
conslmction,only 1 G W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional cages if necessary.
drilled: '
SU3 TT
9.Total well depth below(and surface: 260 ALLNST'RUCTIONS
(p)
pa'nodtlple wells list all depdrs fdytereru rerample-3Ca200'and 2@t1003 24a. For All 'Wells: Submit this form within 30 days of completion of well
is abaft•c»sing,use 2�
Jnvter'ford is construction to the following:
10.Static t s ra
level halos of casing:sing. Division of Water Resources,Information Processing Unit,
"+"
1617 i/Iall 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 puck,ern.) construction to the following
FOR 4i`AT_ER SUPPLY WGI,r S ONLY: Division of Water Resources,Underground Injection Control Program,
/J 1636 IN-Tail Service Center,Raleigh,NC 27699-1636
13a.Yield(glint) O Method of test. air pressure 24c.For:inter Su¢nlr E.Injection Wells: in addition to sending the form to
granular the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: 9 Amount: 0'L completion of well construction to the county health department of the coumv
cohere constructed.
Foml North Carolina Department ofEm•imrmenml Qaali,Y-Division oFlvmcr Rezou.ecv Rcmcd 2-22-0I6