GW1-2021-06910_Well Construction - GW1_20210505

RECORD GW 1 for Infe€Da)Use Onl5r t
I.Well Contmetorltnfor oration:
Chris Morgan 1 14.WATER ZONES l
1Vell Contractor Name IMOM— TO I DES PRIOR
3572
fL ft.
NC XVell Contractor Certification Number tar OUTER CASING(for tuuiti-atsed welts Olt LINER r. ncabte)
Morgan Well&Pump, Inc. FROM To DLMIETER I TSlcr(rMS MATERIAL
+1 ft- (' ft. 61h6 in. sd2t pvc
Company Name (( f 16.INNER CASINaG ORTUBMG(eothermal Oused-too
2.Well-Construction Permit#:_ L � �r"� r•Roai I To I DIAMErElt I THICKNESS I RIATEWL
List all applicable uvll construction permits(i.e:UIC,Coheir:State,110r)ance era) CL ft: in
3.WeIl Use(checl:well use): ft.
Water Supply Well: mp i PTO I DIAMETER SLOTSl=, THtCI ESS I MATERIAL
Agricultural DMunicipallPublic ft €t. in.
�Ceothermai(Hell ing(Cooling Supply) i&Residential Water Supply(single) ft. rt. in.
31ndustriallCommercial DResidential Water Supply(shared)
18.GROUT.
hli ation f•Raai I To I MATERLIL I EttipLAcEa1ENTaiFTHoDr.Antoutvr
Rion-lhlater Supply Wall: 0 fL 20 ft. bentonite poured
D11•ionitoring ORecovery €t.
Injection Welt: fGft- ft.
PAquifer Recharge OGroundwater Remediation
I9.SANDIGRAVI LPACIC(iia llcable).
DAquifer Storage and Recovery OlSalinity Barrier I FROM I To I MATERrAL I FatPLACEMEh-r alFTsaD
Aqulfer Test OStormwater Drainage ft. ft.
Experimental Technology QiSubsidence Control ft. ft.
Geothermal(CIosed Loop) QlTracer 1 20.DRILLING LOG(attach additional sheets If necessary)
FROMTO DFSCRiVnON color.hardacss,solll=4 t c.ara)n Am,ete.)
Gcothemiat(Heating)Cooling Return) Other(explain under#21 Remarks}SS 11. 27 ". oc►�rt � jZ�-
4.Bate Well /s)Completed: !t 2- Z'i Well IDT f i/a tD 4. -?--5� % ,s'
5a.Well Location:
n/a 96
Facility/OwncrNarm; Facility iDp(ifappiirab)e}
tt �bA £t qD rt.
Physical Address,City.and Zip j/�l it. ft.
t e.s t, \._ !(ai $�� 21.REMARKS nw r v .- ?
l s�
Count/ Patccl ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ulm
X
(iftvettfteld.one lattlongissufficient) at_ 22.Cte�rticaion:
� J9-/ G N� y
At-
,,-[ to
6.Is(arc)the ncll(s)0Permancnt or OTemporary Signature of Cerf0d tVclirConntractor Date `
1ty signing this fonn,i hereby certify that Ilte tvall(s)lvas(were)constructed in accordance
7.is this a repair to an existing well: DYcs or is No tvith 15A NC•1C 02C.0100 or IS:f A'CAC 03C.0200 Well Construction Standards and that a
If this&a repair,fill oat knot%*t wall construction information anti eqt/aht Ilia natura of the copy of this recordhas been provided io the well onmar.
repair under#21 remark section or an the back.of thhvfbmi.
23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,Only I Gr 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' SUMEITTAL DIST RUC TiOPIS
9.Total well depth below land surface: { } 24a.For All VVIells: Submit this form within 30 days of completion of well
For nutltiple tvally list all depths fJ•differew(erampie-3@200'and�2ftr 1001 construction to the following+:
10.Static water level below top of casing: 7 0 (ft.) Division of Water Resources,Information Processing Unit,
If ttuter level is above casing,use"•t-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 242
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground-injection Control Program,
FOR WATER SUPPLY WEt,"LS ONIX: 1636-Mall Service Center,Raleigh,NC 276994636
13a.Yield(;pm) 'r Method of test: air pressure 24c.For Water SuDniv&infection Wells: b addition to sending the form to
the address(es) above, also submit orie'copy of this form within 30 days of
I3b.Disinfection type: granular Amount: ©� completion of well construction to the`county health department of the county
' where constructed.
Fonn GW-1 North Carolina Department ofEnyironmental Quality-division or water itcsou,ces Reviscd 2-2 -2016