GW1-2021-06934_Well Construction - GW1_20210505

—mn-,w u..v, Vg z k xa i4.:T10N RECORD(M For Internal Use Only:
1.WelI Contmetorinformation:
Chl9s Morgan L d 14.)VATERZONES
tVell Contractor Name FROMt TO DESCRtMLON
3572 fL n. F
ft. ft.
NC%Veii Contractor Certification Number ,,,, ��ni l^*��� g,OUTER CASING(for malti casedicvclts 08 L R(tr. n¢ablo)
Morgan well of Pump, inc. 1"iiUll,�3'=�_`'n t`'n
~Y T FROM TO DtAMtM T$ICIGMS MATERIAL
t {r�?dr;t;0il
Company Name , +1 Ift• tQ ft. 6 t18 in. sdt21 pvc
W2 } „� C)C>�� 16.INNER CttSING OR i USING(eothermtit closed-l000l
2.Well'Construction Permit#: •1 PROM I To I DIARISTrit I THICKNESS I ;%I, RIAL
Gist all applicable a-eli cotssrntction permits(i e.u1C,Count.State Parlance,erc.) It. ft. in.
3,Well Use(elieckwell use): ft, ft. in.
Water Suppiy Well: 17.SCREEN
MOM TO I DIA51ETER SLOT SIZE THICI(MBSS MrATE
Agricultural Municipal/Public ft tt. ta.
DGcothermat(MmithigiCooling Supply) residential Water Supply-(single) ft. ft. in. t
�ilndustrial/Commercial DResidential Water Supply(shared) 18 GROUT
lnigation PROA1 TO M4aTEltLtL GMIPLACEMIEtriMILrtiOD&AMIOutvT
Non-Water Well: fL za ft bentonite poured
Monitoring ORecovery ft ft.
Injection Well:
ft. ft
Aquifer Recharge oGroundwater Remediation
Aquifer Storage and Recovery OiSalinity Barrier 19.sROa /GRAo L PACIC(if SAT'@R�Lle} EMtPLaC[Mt&n-r ktFTFIOD
Aquifer Test OStotmwaterDrainage ft, ft.
Experimental Technology C !Subsidence Control It, ft.
Geothermal(Closed Loop) (]iTlacer 20.DRILLING LOG(attach additional sheets if necessary)
Gcothomial(Heating/Cooling Return) ' - Other(explain under-021 Remarks) FRoar To DEscRIlnTox color,hardness salttmctr t{'G aratn s'trr Cta1
(j ft t ft
4.Date Weil(s)Completed: '?'1 well M#nha I?• 6 ft. VO rut—^- V1--c4—
5a.'Well!vocation: ��� It. ft.
Facility/OwncrNa_mic�* Y� Facilityll)'(if applicable) It. ft•
Physical Address,City.and Zip
C,l nc o V2, 13 U1-R1:WAIucs
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutesiseconds or decimal degrees:
(ifwcll field,one llat/loo/nggssiis sufficient) 22.Certification: t
r-It POT
i . lff�i3 _•-- f•
6.Is(are)tile well(s)OPermanent or OTemporary Signature ofCertifiid1VcliContractor Date
B}'signing ibis form.1 hereby certify!hat rite mil(s){vas(were)consinicred in accordance
7.Is this a repair to an existing well: Dyes or n iio trills I5,1 A'C4C 02C.0100 or 15.4 htCAC 02C.0200 Well Constnterion Standards and drat a
If this is a rapair,fill out known wall construction Infanutlon and mplain the nature of Me cap},of this record has been provided to lhce%roll ouner.
repair under 4121 reniarkr section or ort die back ofiltisforrn. 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{yell
construction,only 1 GAr- is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessaTy.
drilled: ' SIJBM-TTAL MT-RUCTIONS
9.Total well depth below Iand surface: {fi.) 24a.For All Wells: Submit this fond within 30 days of completion of well
Far multiple wells list all depllts Ifdiifferen(example-3@200'aannd 2@1001 construction to the following.
10.Stntle ivater level belofd tap of casing: C o (ft.} Division of VVater Resources,Information Processing Unit,
If stater/erel is above cursing,use"t" 1617 mail Service Center,Rnleigb,NC 27694-1617
11.Borehole diameter: {in.} 24b.For injection Wells: In addition to sending the farm to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.WeII construction method
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY VM,LLS OTR V- 1636 Nail Service Center,Ibleigh,INC 27699-1636
13a.Yield(;pm)___. +�!_ _ Method of test air pressure 24c.For Water SuDDIv&'sniection i Wells: In addition t0 sending the form to
the address(es) above, also submit dne copy`of this form within 30 days of
13b.Disinfection type: granular Amount: L 4�.• completion of well construction to ffie county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviroarncntat Quality-Division orwater Rcsou=C5 Revised 2-22-20 t6
I