GW1-2021-06918_Well Construction - GW1_20210505

o For Tnt . ......"....emal Use Only.
I•Well Contractor lr ftformation:
Chris Morgan
14.1irATER20NES �
ltrcll Contractor Name �
[Tt011 TO DESCRIPTION
3572
NC-Veil Contractor Certification Number IL ft.
Morgan Weli a Pump, inc. Is.OUTERCAUNG(for multi-casedhvelis onfo- r• ticabto)
I'ROPr TO DIMETER 1HICI4YESs
Company Name +1 ft. n ft. MnTERiett.
.$ 611e in• sd2l pvc
2,Vttel!'CDnstructianPermit#: V7gS— IG.INNERCASINGQRTUBING(eothermalclosed-too
List all appl/cahle will constriction permits(i.e T//C,Cotngi:State,YariancG etc) FR°11i TO DIABtETER TgtCi i Est
fL ilL1TERLiL
3.Well Use(cheep well use): 1n
Water Supply Well: ft. ft. Ia.
17.SCREE
Agricultural DMunicipal/Public rROM TO D1Ap1ETER SLOT SIZE
Geothermat(Heating/Coollm, re tCirnEss M1LITEMAL
Supply) F&IResidential Water Su t 'sin le to
Dindusttial/Commercial pp y( g ) It.
DResidential WaterSupply(shared) ft. in.
hliaation 10.GROUT.
!Von�Water Supply V' FnonT To ti1A�
EIHPLACENIENT,11L•THOD&AMOUNT
ilianilDrine 0 ft. zo ft. bentonite poured
Injection WeIf: 011ccovery fr
fr,
Aquifer Recharge oGroundwaterRemediation ft. ft
Aquifer Storage and Recovery E]Galinity Barrier FROM
SAND/GRAN]L p,LCg(if a itcable
Aquifer-Test FRODT TO NTATERTAL
ft. EatrtAcr•.MEnT atsrtroD
QlStormwaterDrainage
Experimental Technology ft.
EJ ISubsidence Control ft.
Geothermal(Closed Loop) tt.
QITraCar 3a.DItII LING LOG(attach additiooat sheets if necessary)
Ocothemlal(Heading/Cooling Retain) : . Other(explain under 021 Remarks) �O1S
T DESCRtPTiOti coto,hardLness,I owracli It a Stain sac•ctc.t
ft. � ft. � "�
h.[Date Wells)Completed: - $1j, at
Neil IDf>:n�8 D R, it.
Sa.Well Location: ro
V e_e- n/a 8(pft. 6 ft. VC.
Facility/OtvnerNiRnc C4nr
t /� Facility lDp(ifapplicable) Oft• ( G ft. / r
G. Y S Ct/l 1 J{ ✓L1(jU fe (/f 1�ti` ft. ftfir
Physical Address,Cu},and Zip
ft. ft.
21.RE,MARics ,` ¢
County Y,�r�
Parccl Identification No.(PiN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one fat/long is sufficient) t
.?' V Y yea'+. 1 ) ?
22.Certification: i^ tk, m '� s .1K Ij1
—_ YV i f�� /� �i11Gi d -!oil
6.Is(are)the well(s) V
3• Permanent or O T emporary Signature ofCcrtig it Wcil Contractor --
ale
9.1s this a repair to as existing well: Dyes or :)Igo By,signing this fann,I Iterabp certO,ilia',the nall(s)uas(were)ronstnicted in accordance
Ijthis Lr a repair;fill out known well construction infonnouan and explain the nature ofthe c p)•of this record has been provided tv t e,Y j 0%t,well Construction Standards and thou c
repair andar#21 rentorla section or on the back of this form.
23.Site diagram or additional well details:
G.p'or Geoprobe/DPT or Closed-hoop Geothermal Wells baving the some You may use the back of this page to provide additional well site details or well
construction,only 1 W-1 is needed. Indicate TOTAL NUMB
drilled: ' ER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUB HTTAL INSTRUCT IONS
Fa nnrfttple[tells I(sr all deprlus fd0rerenr(eram le-3 > > (".) 24a. For A11 ilrells: Submit this form within 30 days of completion of well
p @_ao•and_@/U0� construction to the following:
10.Static lvater level below top of casing: 4Z 0
if tracer larel is above casing,use r (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.)
24b.For iniection Wells: In addition to sending the form to the address in 24a
12.",Veil construction method: fOtSly above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR'WATER SU=%LLSi,: Division of Water Resources,Underground Injection Control Program,
1636 iv?ail Service Center,-Raleigh,NC 27699-1636
23n.`field(;pat) iviethad of test: air pressure 24c,For Water SunnIy iniectioti 1yells: In addition to sending the form to
13b.Disinfection t3 pe: granular Amount: the address(es) above, also submit lode copy of this form within 30 days of
�-cJ 8-L completion of well construction to the county health department of the county
where constructed.
Form ow-1 North Carolina Department ofEnviroamcntat Quality-Division of\Vater Rcsoutcrs Revised 2-22-2016