GW1-2021-06969_Well Construction - GW1_20210505

a Ae.N R]EC
For Internal Use Only .. ...
I,Well Contractorh&ornlation:
Chris Morgan
R'ell Commeror Name 14.tiir4TER20NES
3572 FRohr ft. TO DESCRIPTION
R,
NC Weil Contractor Cettifi-ation Number R ft.
Morgan Well&Pump
inc. 15 OUTER CASING Mor maltt cased volts ORLi1VtR Ea ncablo)
IR051 Company Name TO DIAbIETER Talc biATERiAL
fG 61/8 in.
sdr22.W01MOnstruction Permit#..L.iO.) I , , 16.INNER CASING ORTURING{eotherm all ed-loo ciasl PVC
Lilt all appllcahle Well construction penmts(r,�lJ/C,Cortn(i;$tat&Variance etc) FRat TO DIAh1ErER
TEIICICNL,SS h1ATERLht,
3.Well Use(chedcwell use): R. 3Q'
11
Water Supply Well: ft. R lo.
17.gCREEN
Agricultural Municipat/Public rttoht TO arahtETER slorstzt
Geothermal(Iicating/Coolin Su 1 fL tw tR Tillcla�Ess mrATERInL
B pp y) Residential Water Supply'(single)
Industrial/Commercial r""Residential Water Supply(shared) f t R• to
hrigation Ill.GROUT.
Pion-Water Supply Well.. Mom To h1ATERrAt
EhIPLACEhm-NT hirrHon&AMOUNT 1\40nitOring 0 R' bantonile
Injection Weli: (]IRecovcry poured
D• ft.
Aquifer Recharge [Groundwater Remediation ft.
ft:
Aquifer Storage and Recovery []ISaliniry$airier 29'SlGRAVEL PACIC if a ticable)
Aquifer Test FRohr ro htATERrAL
OStormwater Dminage ft. EhiPLACrNl-hT,--ETHOn
Experimental Technology 17--% ft.
:)Geothermal(Closed Loop) QlSubsidenee Control ft.
ft.
QITt her 20.DRtr.;LNG yOG(attach additioaai sheets if necess
Ccothcrnlal(Hearinn�Cooling Return) � - Other(explain under#21 Rematits) �011 )T° DESCRIPTION color,banlaess,salVmcic 1 S rraio size etc)
4-Date IVell(s)Completed: J3 Well W#n/a
b ft.
Sa.Well Location:
I5 fr. n.
n/a ft. .
Facdiry/Owner Namc Facility iDs(ifapplicable) g• I
I ft.
rC �Z�d ft. ft.
Peal Addres ity,and Zip
ft. ft.
1 ,a-i I
�21.. ilia v
21.RERIAM{S
County
Pa 1 Itientific-tim No_(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: RAYJ
(iftvell riald,one lat/tong is sufficient)
!35•fir// 22.Certification: s;OG rfjfc�S�s[l I�iil
C110 N Sb.St3�7 W, :� i�lf��l�,
6.Is(are)the well(s) PelalI '''' 11/13-
aaeat or []I3emporary SigttaturcafCenifjtd wcu Contractor Del
7.Is this a repair to an existing 1vell: YCS Or No By signing his fomr.I hareby certth that the st ell(s)tvas(vem)constricted in accordance
lfthv is a repair,fill an bvtotvn rvell construction infommtion and explain the nature ofthe c P1'ofthis record hasOb t er provided to do well owner.Well Coartrrtctfar Stardands and that a
repair under#21 remarks section or on the back ofthisfornc
S.For d',eo robe/F)P 23.Site diagram or additional well details:
P T 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: Q SUi3iidtT 1�'INSTRUCT IONS
ForrnultfpleuellslistalldeptluJdLerent(eraarple-Or (`) tea•For A]I t�'eDs:
10.Static grater level below dap of casing: Submit this form within 30 days of completion of well
b construction to the following:
Ifnuter level is above twitig.use-+^ (ft.) Division of Water Resources,information Processing Unit
11.Borehole diameter: ,
2617 NMI Service Center,Raleigh,NC 27699-1617
(in.) ,,
24b.For Infection Wells: In addition to sending the form to the address in 24a
12-Well construction method: rotary 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:
rQR WATER SUPPLY 1hrELLS ONL4r. Division of beater Resources,Underground Injection Control Program,
1636 Aria!]Service Center,Raleigh,NC 27699-1636
13a.Yield(gpni) Method of test: air pressure 24c.For Water SllDDIP&Infection iWells: Tn addition to sending the foal to
13b.Disinfection type. granular the address(es) above, also submit one copy',of this form within 30 days of
Amount: t1)b? completion of well construction to the county health department of the county
where constructed.
Fotm G1V-1 North Carolina Dcpattment of Environmental Quality-Division of water Rasouras
Revised 2-22-2016