GW1-2021-02153_Well Construction - GW1_20210505

orinlemajUseOnly:
I.Well Contractorldormation:
Chris Morgan 1 14.NVATERZONES
\Yell Contractor Name MOM To I DESCRIPTION
3579 JG It. ft.
ft. ft.
NC 1Vell Contractor Certification Number to.OUTTNtt casrtc Mor asulti eased tiveus oR LtNEtt r. ucanla
Morgan Well&Pump, Inc, MOM To DtAMiETER TBR:IGYFPS MATERIAL
Company Name +1 ft' ft' 6 118 in. sd2 fr
1 vc
fj 16.INNER CASING ORTiiBiNG(eathermal closed-loop)
Z.Well-Construction Permit 4: C7 r•Rom I To DIAMETER I THICKNESS I MATERIAL
List all applicable wall consttrtetion penaits(l a UICG Counp;State.11ariance etc) fL ft. rn
3.Well Use(checkivell use): it, ft. is
Water Supply Well: zrROAI
REEN
MOM TO DIAMETER `. SLOTS THICIMTM MUTE
Agricultural DMunicipaltPublic ft ft. In.
IDGcothcrmal(HcatinglCooling Supply) Residential Water Supply'(single) it. ft. fn.
31ndustrial/Commerciai DResidential Water Supply(shared) ROUT.
Irrigation I To I MATERIAL IEMtPLACEMtEnTMrtruOD&AMtOUhT
Non-Water Supply Well: 0 fr. 20 ft bentonite poured
iioniturin; DRecovcry Ift ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAM PACK if a llcabic
OAquifer Storage and Recovery QlSalinity Barrier fz To MrATERIAL EM:rr acERSEnT 1sETHaD
tquifer Test OStormwaterDmiinage ft.perimental Technology QlSubsidence Control othermal(Closed Loop) QiTracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION color,hordoemsoIl(racliis e.stain sizes cm)
othermai(Heating/Cooling Return} Other(explain under�.21 Remarks} 4 ft. ZO) ft. �.
4.Date Well(s)Completed: �{ r� +~�°� Well le R fi�8 d �. p ft. '9 ypt»'J -�
5a.Well location: ft, / ') S QtA,
f tie4rle5 C)4fdt�r' n!a S fk. ft. ii� tLn'
Facility/OwncrNatnc Facility iD",(ifappiicable) ft. ft.
ft
Physical Address,City.and Zip ft. ft.
S*3 f I 'i.REMARKS '
t
County Parcel Identification 14o.(PIN)
5b.Latitude and longitude in degreeslmiautes/seconds or decimal degrees: `�
(ifryel{field,one iat!long is sufficient) 22.Certificatioa:pOyiw, iM �a On
;
6.Is(are)the tyell(s)2t Permalteut or �iTemporary Signature of CcrtI", Well Contractor Date
By signing rhls f tm,i lrerebj,cerrify tint rile rrell(s)wmr(were)constntcted in accordance
7.Is this a repair to an existing well: t}ZCS or n NO nvtlt ISA MC-4 02C.0100 or]SA h'CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill ant know,wall eonstntction infonnatitnt and explain rite nature of the copy of this record has berm provided to tho well owner.
repair under Q1 remarks section or on the back of dtiaform. 23.Site diagram or additional well details.•
G.For Geo robe/DDT or Closed-Loo Geothermal Wells having the same You may use the back of this page to provide additional well site details or wen
p p construction details. You may also attach additional pages if necessary.
construction,only 1 Cr1'N�l is needed. Indicate TOTAL NUMBER of wells
drilled: ' SUBATtTTAL rn;STRUCTIONS
9.Total rrell depth beloiy land surface: ?,'ego Cf,.} 24a.For.All Wells: Submit this farm within 30 days of completion of well
pbr multiple wrlls list all depots lfdierent(erampte-3@200'annd 2@1001 construction to the following:
10.Static crater level below top of casing: F Q (ft.)
Division of Water Resources,Information Processing Unit,
(f%aterTavel is above(.-using,use 1617 Mail Service Center,Raleigh,NC 37699-1617
11.Borehole diameter: Fi (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division ofWater Resources,Underground injection Control Program,
FOR WATER SUPPLY mil`MLS OM: 1636 Mall Service Center,Raleigh,NC 276994636
13a.Yield(gpm) ✓ i4'iethod of test: air pressure 24c.For Tinter SuDDIv&iniection Welts: In addition to sending the form to
�y the address(es) above, also submit one copy'of this form within 30 days of
13b.Disinfection kype: granular Amount: �-+ completion of well construction to the county health department of the county
where constructed.
r �lorth Carolina Department of navironmentai Qtwtity-Division orIugter rtasoutecs Revised 2-22-2016
Form G«-1