GW1-2021-06948_Well Construction - GW1_20210505

QRDGW .............
Forinternal Use Only. - -- .. ..__...
?•AVeli Contractor Information:
Chris Morgan
well Contractor Name 14.R'ATER20.NES
FROM TO 3579 DFSCRIPTlON
rt, n.
NC well Contractor Certification Number fL ft. i
Morgan Well& Pump, Inc. FRONT RONT R cwtrm�s r 3 -cased Wells OR L MR rn ncable)
TO DWI' R THICIOWs NTATERLAL
Company Name +1 ft. ft.
6118 in, sdr21
�(ic
16.INNER ( pvt
2.Well'Construction Permit#; GORTUBING eothermalc)osed-loo
List all applicable hell coartnrc8on pernutsU/C,Cotwq:Srate.marl....etc) FRONT TO DIAd1ETER THICKNESS
11�fTEltlAl,
ft. in
3.4irc1111st1(checiimve)l use):
R• R. !a.
Water Supply Well: 17.SCREEN
Agricultural DMunicipal/Public FRont TO DIAniETER SIATSIM
Geothermal(Heating/Cooling Su 1Water
tt ft to TH[CIeA•ESS nL1TERIAL
Pp y) [. ,Residential WaterSupply(single)
industrial/Commercial DResidentiai Water Supply(shared) ft' tt. in
Irrigation iff.GROUT.
Mon•Water Supply 4Velh FRONT To ft
NATERtAL En1PLACENLENT NI ruon&�ntouns
il4atrail ng Recovery o ft 20 bentanita poured
?njection Well: l� tL R.
Aquifer Recharge Groundwater Remediation fL ft
Aquifer Storage and Recovery QlSalfnity Barrier 39•SaND/GRAVEL PACIC ifa ucablc).
Aquifer Test FRONT TO M1tATERtaL
QlStotmwater Drainage }}, £M1TPLwCFM11EhT 11ETHOD
Experimental Technolog3' F°
[]ISubsidence Control ft.
Geothermal(Closed Loop) [],Tracer ft.
Geothermal(Heating/Cooifn Rettrm 20'DRILLING LOG(attach additional sheets if aecess
g ) Other(explain under.21 Remarks) oNT To DESc l o. color,turdacu,salUmNr 1 4=to S17A eta)
4.Date Well(s)Completed: Welll l.m n/a Q ft. Zs
Za tc. fr. h
Sa,Well Location: 3S 14
35 ft. o ft.
n/a (op a. Zm n 1 V
Facility/OtvncrNamc GIYtFacility fDR(ifopplicable) ft. R•
84isl, �o�� ,Kd 2 ,�-
kar►harb6s NC 3 ft. ft.
Ph srca!Address,Cn),and Zlp v� `
ft. ft. +
n!a z1.REivrARlcs
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lotilong is sufficient) p r J J�p1
�5LL -1 pb. �ZQ I 22.Cer'tification:
N
v w i�
6.Nara)the well(s)�fX Permanent or OT•emporary Stgnatum of eerii d well Contractor
t Da
7.Is this a repair to an exlstin well: �—� or BI=signing this fomr.I hereby cert�Mal ilia itmU(s)ttiva(were)constructed in accordwice
!f this is a repair,fill wit 6•nown tvel ronstnrc6on nfannation andexplain ilia mm�re oftbe trill'coP1'of t15Ahis AC 0-car liar' 10m pr0 or ovided N to/c 2C-200 W Well Constntctiwr Standards and that a
No
repair tinder m21 rrwarls section or on the back ofllttsfornt.
23.Site diagram or additional well details:
S.1:or Geoprobe/IDff or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-f is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMIT TAL IR'ST•RUCI IONS
9.Total well depth below land surface: (fL)
F 2411-1?or All wells: Submit this form within 30 days of completion of well
w•nnrlrtple walls list all depths ijJ�ererrr re -3Q30U'and ZQ/U0�le
construction to the following:
10.Static water feral belowtop of casing: 3 if i (}�)
nter level is above casbrg,trse +^ Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
1617 Mail Service Centex,Raleigh,PIC 27699-1617
(in.)
24b.For Infection t•6 ft In addition to sending the form to the address in 24a
12.4Vell construction method: rotary above,also submit one copy of this form withia 30 days of completion of well
(i.e.auger,rotary,cable,direct push,crc.) construction to the following:
FOR WATER SUPPLY,('ELLS ONLY: Division o€%Vater Resources,Underground Injection Control Program,
1636 Nail Service Centex,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: air pressure 2qc For Water =Iv&Iniectfon Wells. In addition to sending the form to
13b.Disinfection tj pe: granular the addresses) above, also submit one copy of this form within 30 days of
Amount: JI6L completion of well construction to the county health deparanent of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Qualhy-Division oflvater Resources I
Revised 2-22-3016