GW1-2021-06974_Well Construction - GW1_20210505

1;1_�UN RECORD
For a]Use only:
1,1yell Contractorinformatione
Chris Morgan
A'ell Conttacror Name _ 14:tii:4TER gOIVES.
3572 `a 9 " Ftt01I fG TO DFSCRtPTtON
fit. f
NC tVell Contrnetor Certifiption Number 1e6 yY X J LO�� fit. {t,
Morgan Well& Pump, Inc, n,,. pr it ()(il is OUTERCwsatVfs ormatt-ca6¢dvcnOR LR rnrRO1 TO D[A1EER ncaaCompanyNamc e b
::IAT
�tiUi"�. u• +1 ft. t� fit. 6118 ' in.
sdr22.Well'Construction Permlt#: 3323°��] 16.INNER CASING ORTUIING(eothermat closed-loo pvc
List all appllcahle will canslrrctionp a rRO11 TO DIAMETER
+mils(i.a UIC,Corrntt:Stale.Variance~etc) THICIiNEsS 1Z•1TL•RIAL
3.Well Use:(check well use): tt' I"-
Water Supply Well: ft. ft. In.
17.8GREEN
Agricultural rItOrd TO DIAM1IErER SLOTSIZE
Geothermal(Hcating/Coolin Supply) QlRaslde tial Water
TxtcrrnEss M1LITERIAI
S PP Y) �tRrsldentiai Water Supply-(Single) fit tt. ro,
Industrial/Commercial ft.
DResidential Water Supply(shared) ft. ,u
htigation 18. OUT.
Non•Wnter Supply Well: r•Ron1 TO 17ATERIAi
0 EM1iPLACEM1IENT 11ti1 xoa&antotncr
!\4oniloring I-•t� 2 R' bentanite
Injection Well: ORecovery poured
Aquifer Recharge fir,
Groundwater Remediation fir.
�IAquifer Storage and Recovery EllSalinity Barrier 19 S /GRAVEL pACiC if a iirnble.Aquifer Test FRO&I TO LMI cAL
oStottmvater Drainage g, fit, eM1trr acr•.n�>rrr art rrroa
Experimental Technology
Geothermal(Closed Loop) OlSubsidence Control fit
QlTracer ft.
Ccothcm1al(Heating/Coohn Return 70'1�I2ILLING LOG(attach add iliaaal shoots if necessary)
g ) Other(explain under#21 Remarks) FRo1r To DESCRIPTtox color,hsrdnr7s solUraetr 1 a crate srZC eta)
4-Date Wells)Completed: 't a-� n/a C> ft. a`5 fr. r 1 r
Well ID# a s fit. 35 ft.
Sa.Well Location: tt brbw%0L Air t-
_ 1(-��r P1'oln n/a 35 ft. SS �' }�ro%A ytc.k
F ty/OtvncrNamc 55 '3O0 rt ��tF� raHl
Zorh Facility ID"(iFapplicable)
WoO� dr. �.k3c l� NG ZVI7 ft. ft.
Physical Address,Ctt} anJ Ztp
tt. ft.
OW!!►1n n/a 21.RirIYARICS
County
Pateel[dDmi&cation No_(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lon, Certification.
is sufficient)
-3 5•rj'�g 22.
N —So..5o(oa W ;:
6,IS(are)the well(S)OPermanent or oTemporary Signatu
1� �taeut Datc
7•Is this a repair to an existing well: YCS or NO By signing tltis font,I herebp certify dial lira urll(s)ices(ware)mnstrncred in accordance
p�i is a repair•fill art knoav well constrnctian information and arplain the nature of rdth roPJ'of h1Nr!fie n d I ar b�cOm�rl�id N/ / �,C����C ell Conrtnrcliar S/andae�r and that a
repairmrder ir31 rnntar/ssecllon or on the back ofllrisjornr.
onal well d i
S,For Geo robe/')_T or Closed F,00 Geothermal Wells having the some YOU
maydiagram he back ofhthis page to provide additional well site details or well
p � You m
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 is-all depth below land surface: Soo SUBMITTAL INSTRUCTIONS
ror na itple Wells list all deptits#dii erent(2r(iap1e-3@200'aird 2@1001 0") 242- For All Wells: Submit this form within 30 days of completion of well
10.Static stater level belowtap of casing: construction to the following:
T imfer lerei is abovecnshtg.Ise J��;^ (ft.) Division of Water Resources,Information Processing unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,PIC 27699-1617
(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12,iVel1 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,underground Injection Control Program,
1636 Nail Service Center,Raleigh,INC 27699-1636
13a.Yield[gpm) / Method of test. air pressure 24c For Water Sunnly R.
Tniecfion iWcils: In addition to sending the form to
I3b,Disinfection type- granular ii Amount: dZ- the addresses) above, also submit dne copy:of this form within 30 days of
1 completion of well construction to the county health department of the county
where constructed.
Form GtV-I North Carolina Department of Environmental Quality-Division of Water Resoures
Revised,2-2-2016
i