GW1-2021-06915_Well Construction - GW1_20210505

VV1L,1L �UNST tUCTrnw uvOORD
For Tntemal Use Only: __T
L Well Contractorinformation:
Chris Morgan
11'ell Contractor Name 14•WATER ZONES
Motu TO DESCRIPT10rY
3572 19 S ft. SU ft,
NC Well Contractor Certification Number ft. :
Morgan Weft&PuMp, Inc, is.Ot]T);RCASING(formniti casedlwclls ORLMER(ir. ncabte)
DRODI TO DWIETER Tl:C1G+lESS dtATERIAL
Company Nance +1 ft, t• 6118 in.
n 1 sd21 pvc
2.Well*Construction Permit#: V S I6-INNER CASING ORTUBING(eothertnal closed-loo
3 FROM TO DtA&IETER all applicable will coil usei permits(ie:UiC,Cattnn:State.lrariance etc) ft ft. in 1 HiC1fNESS MATERIAL
3.Well Use(checlavell use)::
ft• ft. In.
SMAgricultural
tatei upply jlVe :
�MunicipalMublic FROM TO DIAMETER SLOTSIzE THICIQ�ESS nL1TERiAL
�30eothcrmat Hcatlns/Coolin Supply) Residential Water supply-(single) n• in.
( g PRY)
pindustrial/Commercial
[]I ft,
Residential Water Supply(shared)
fmgation 10.GROUT.
Non-W ter Supply Vden; MOAT T° 17ATERIAL ESIPLACEntElvr,"IET IOn E 1nt°unr
I�tonirolI L t—t' 0 fL Y0 ft• hentonite poured
injection Well: [�IRccovcry tL
ft.
Aquifer Recharge oGroundwaterRemediation ft. R
Aquifer Storage and Recovery []ISalinity Barrier 19•ST/GI O PACIC if a ticabie)
Aquifer Test FRONT TO ATATERTAL PIiPLAC ETHOD EtIiETTAT
QlStormwaterDrainage ft. ft.
Experimental Technology
ISubsidence Control
Geothermal(Closed Loopj ITraczr ft. ft.
20.DRR LING LoG tattacIt additional sheets If necessary)
GcOthem)al(Heati�ng/Cooling Retttm) Other(explain under;r21 Remarks) 011 T°
ft. O ft.
DESCRIMOIti color,hanlams,sainroclt lt'c,eiata size,eta)
O :A
t.Date Well(S)Completed;i/_Z 2"Z I Well 127;i:(1/$ 0 tr. Ott.
5a.Well Location: d ft. 7 s" ft. S tl o-
•
rxnld����lJ�, s n/a ' rr. �� rt.ry/OtvncrAlamc n Facility ID-,(ifopplicable) ft. ft.
!� 5- �&%,-s .,. y f ut Ci$��J ft. tL
$Physical Address,City,and Zip ft. ft
Fred e I k RrG- A- 21.RErr,Altics P
County Parcel Identification No.(PrN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I MAY x J
(ifiveil field,one lot/long is sufficient)
SI p 22.Certification: Ist v;' ,ii;ri::il i�tC�CuS! r Ulil
d 0
4,73
b.Is(are)the weU(s)OPermaneat or OTemporarY Stgnoturc ofCenifEd 1Vc11 Contractor t
Date
7.IS this a repair to an existing well: Qt � Bj>signing this jam:,1 herebJ'cert6 that die Well(s)ryas(were)constructed in accordance
e lees or n No with MI A'C.aC 02C.0100 or I5:4 A'CAC 02C.0200 Well Come ruction Stnndo
Ifthis is a repair,fill ant knotva swell constnrction infonamimh anti explain die nature oftha cap,ofthis recordhas been providedis tho ic n el!umer. rdr and that a
repair under 01 rentarkr section or on the back of this four.
23.Site diagram or additional weU details:
5.l or Ceoprobe/DPT or Closed-Loop Geothermal 1vells having the some You may use the back of this page to provide additional well site details or well,
construction,only 1 G'V-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t-
9.TotOt well depth below load surf SL31id-1 111AL RISTRUCT IONS
ace: _ � (�L)!%oraurltiple it-ails list all depths jdLeretir re -3@200"and 2@1U0l 24n-For All Wells: Submit this form within 30 days of completion of well
r9 construction to the followitl;
10.Stntic water level below top of casing:
If ivater level is above cashig,ttse'+ Division of Water Resources,Information Processing Unit,
i I.Borehole diameter: 6
1617 Mail Service Center,Raleigh,PIC 27699-1617
(in.) ',
24b.For Injection 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
(Le.anger,mtam cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY We'ELLS ONLY: Division of Water Resources,underground injection Control Program,
�f 1636 IbiaU Service Center,Raleigh,INC 276994636
13n,`rigid(;pm) (i Method of test: air pressure ?4c.For adater Sunnfv&Injection Wells: In addition to sending the form to
13b.Disinfection t1 pe: granular - n the address(es) above, also submit one copy of this form within 30 days of
Amount: (/© completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division oF\\Voter Resoivars Revised 2-L�-2016