GW1-2021-06949_Well Construction - GW1_20210505

For Tate .....• ".
mal Use Only:
1.Well Caairactorlltformation;
Chris Morga
CQN
Well Contractor Name 14.lia9TERSONl3S .
3572 OD1 TO DESCRIP'rl
nOi3
NC well Contractor t..ertincation Number fL
1t.
Morgan Well&Pump, Inc. is.ovT>,R CASING(ror mnititnsedYSvolts OR
IROAI TO DIAttIETER � � f. Itcablo
Company Nantc � CrcrrEss nrnTERtAL+1 ft. ft. 61/8 in.
2,WC11'Construction Pe t6 INNER sd2I pvc
rrtult : CASING OR TUBING(eothermal closed-too
!1s/all applicable tressco.......tionpeavnf (i.e:U1C,CanNt:Stare.Variance,elm) PROIIt -f0
DIAMETER THICKNESS lIr1TL•RL1L
3,Well Use(cheep well use); fL ft. in,
Water Supply 111etl: f4 ft. In.
Agricultural l� 17.SCREEN
oMunicipaUPnblic pltOtlt To DL1a1ETF.R SLOTSIZE
DQGeothermat(Hao'k0Cooling Supply) oResidentiat Water Su 1 'sin le rL ft. to. 1HiClrnEss afarERIAL
Industrial/Commercial pP Y( g ) ft.
DResidential Water Supply ft. HL
frriaation pp Y(shared) 18.GROUT.
Non-'Aluter Supply Well
r•Rord TO Al
Monitoring p fL GhIPLA.CEMEATMETHOD AalOuri
QIRCCOvcry ft bentonite
�'Aquifer
jection Well: poured
fL ft,
Recharge r�
[ IAquifer Storage and Recovery013roundwater Remediedon ft ft
QlSalinity Barrier 19.S AND/GRAVEL pACIC(ifa l"cable)
L FRONT ro nIATERraL DStormwater Drainage fr tzniru acr•.niisn-r a1ETtioD echnology ft.
osed Loop) Subsidence Control it.
[],Tracer
1t.
atinglCooling Return) ' Other(explain under r�21 Remarks) 'O DRILLUVG LOG(attach additional if necessary)
q F[tObI TO DESCR1PTtOti color.hardacss sniUmd:15 t errto svr etc)
4.Date t'9lell(s)Completed: —� v� ft. ( ft.
-- Well ID.,- n/a
Sa.Well Location: ft. SS ft. rot4,
�S % Z�v ft. �iC�
Facihry/OwncrNamc —ft. 3 D it.
3 7 Facility IDS(ifapplicable) V r4 a
( Z s-,4 % ft.
resF �GG3�1�/ ft.
Physical Address,City,and Zip r N141 ft.
4r/
n/a
21.REMARICS t�
County
Parcel[dcntificationNo.(PII�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees; r
(if Well field,one lat/lone is sufficient)
22.Certification: CuC�S
CtSbJI�Section
6.Is(are)the wcll(s) Per mancnt or r t ',� /�� 1 lXJ2/
QI_emporary '—_ /Stlmoturc of Ccrti Ika Well Contractor fir' l
GG Date
7.Is this a repair to an existing well: Bp slgniag dais form,1 laereb�>cli dear the url/(s)tvar(here)constrncred in accordance
bYcs or Ido
TIN,is a under
421,fall art known ryes construction infannation and etplafn'lie armnre of the copy of dtis record has been prodded to the hell aumer.
trfdi af' is rec 0?C.O100 or l5A Al 01C.0200 pJell Canrrnrdlan Saandards and dmt o
repair auder�21 ranrarAs sec/Ian or or.Ilia back of thi
agram or
S.I onal well details:
ar GeOprobe/DFT or Closed-hoop Geothermal Wells having the some YOU
Sites use the back Ofhtllis page to provide additional well site details or well
construction,only 1 G6tr t is needed. Indicate TOTAL ATU.MBgR of wells �'ou m
drilled- t r construction details. You may also attach additional pages if necessary.
9.Total ivell depth below,land surface. 3 51V SUB WITTA-L INSTRUCTIONS
For rattr/t/ple 5re11s fist all deprlrs fd(Ilererrr(an ntple-3@30U'a/nd 3@1 U0� ') 2�}a. For All �3'eIls: Submit this form within 30 days of completion of well
10.Static Ivater level below top of casing:_ G construction to the following
0"Voler 1e1•el is above casing.use +^ (fL) Division of Water Resources,information Processing unlit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,PIC 27699-1617
Cn•)
24b.I+or Iaiection_WeIIs: In addition to sending the form to the address in 242
12.Well construction method: rOtal)/ above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rosary,cable,direct push,etc.) construction to the foliowina.
FOR WATER SUPPLY `ELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,RTC 27699-I636
13a,Yield(gent) ' ' ethod of test.- air pressure
24c.For Grater Sunnir Injection Wells: In addition to sending the farm to
13b.Disinfection type: granular the address(es) above, also submit one copy of this form within 30 days of
Amount: Q completion of well construction to the county health department of the count where constructed. .y
I'onn G11'-1 North Carolina Department oMvironmentar Quality-Division oflVatcr ttcsoutCes �
',. Revised=�77 9
.�016