GW1-2021-06975_Well Construction - GW1_20210505

A JUN RECORD GW_J
WeR Contracto _ ormation:
Chris Morgan
Well Contractor Name 14.MIA ZONES
0111
3572 TOZ DESC N
NC lVell Contactor Certification Number X 5 2021
Morgan Well & pump, Inc. IS-011TERCASING(rarmuld
al R5 O'N'r,
TO ble
Rol _R ar.
Company Name DWAIE THICIONESS*
MATERIAL
-7 6118 sdr2l
"c"Con1mcmr.N.m.
377
2'1ye"'COnstructifin Permit 'NER CASING ORTUBMIG othermal closed-IOU pv I c
List all applIcalile ,.ell 16-IN
UC ---- at o DlAht TIUCKNESS MAIM
Col"ItI..State.
rRO T e.1,
3.Well Use(checl,lvell use). artn"Ce.err~)
in.
Water Supply"
Well:
Agricultural
17.ScRrETq
FRONI I TO
G DMunicipal/Public
cuting/CoOling supply) ETResidential Water Supply-(sing,,) ft.EL ft. DIAMEM SLOTSta
cothermat(H
:ETAITEIAL In.' THtcrQCESS �R
IndustrialICOmmercial DResidential Water Sl uppy(shared)
[ "�Inmiggaatrlon -IS.�GROTJ F—_
DI Nonawuter Supply well: Mm".1 TO AT EM AMOUNT
A-lanitoring 0 ft. 20 ft.
­Injection well: 011ccovery fL bentonite poured
t.
QAquifer Recharge OGroundwater Rernediation ft.P(Aquifer Storage and Recove ft.
ry E]ISalinlry Barrier 19-SANDIGRAVEL PACIc
pAquifer Test FROM
L'cal Tr
EPStormwater Drainage ft. To 2H%l gilTAL
t.Experimental Technology [](Subsidence Control 51 F�L_Crl M F Rr�111 F T R 0�u
Geothermal(Closed Loop) ft, ft
Offracer
GrOthermal(Heating/Cooling R 20'DW-LENGLO (attach additional shoe If necessary)
R��etum�, �Other(explain under 021 Remarks) FFRO,I TO DESCPI color.hardams,-
J.mate-vvell(s)Completed: rit.
__0------------Z. well ID,n/a
Sa.Well Location. ft.
—Z-5—ft
n1a LL
A C-kw�� ft. ft.
.,Y/0�,,.r,
�RicilirY/Owncir Name
Facility TD#1(ir.ppli—.bl.) ft.
ft.
cz
Soli yr ft.
Physical Address,ci,3..and Zip
L_>ov— ft• ft.
County go Ll I Ct l U 21.REM
Parccl�Identification No.(PINT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-11 field,one fattlong is sufficient)
22.Certification:
6.Is(arc)tile wall(S)OPermancut or OTemporary Signature Of Cerililgid Wall Contractor
7.Is this a repair to an existing well; Bj?signing liv D21C
Dhis is nrzi out A71osv7, Dyes Or pinto Signing this fang,I herobj?crirlijj,thal4he Ist'll(s)was("'ere)consintcied in accoi'I'llh ISA JN'C.4C 02C.0100 or 15.1 Ali � C -di
CO2 '0200 Well COn-TInictictiSiajtdardsciidiltain
well"Onstniction infanitation anuf e-1plah,the nartire of the, MJ'Ofibis retard has been providedin,the cell 011"er.
repair under#21 renlar*F$Cella or an tie back ofthisfornt.
details:
23.Site diagram or additional wall
rot GeoProbe/DPT 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_ is needed. Indicate TOTAL NUMBER a
drilled: R of AvcUs construction details. You may also attach additional pages if necessary.
9.Totni well depth below land surface; SIJBIM-ITTAL TINSTRUCTIONS
'"'0"11111100 Wells list all del 6rdffl-erent r P,U-3(M-2011 and 2Ca1100J 24n. For All NVens, Submit this form within 30 days Of completion of well
10.Stntic water level below top of casing: construction to the following:
6ritil level is above casing,rise..,11 — UQ Division Of Water Resources,I information Processing U,114
11.Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
te 24b.For Infection'%lis- In addition to sending the form to the address in 24n
12.well construction method; rO' rY above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push, construction to the following:
R WATER SUPPLIZ RTMLS ONLY- Division of Water Resources,Underground-injection Control Program,
1636 Mail Service Center,Raleigh,TqC 27699-1636
13a.Yield Cgpni Method of test: air pressure
24c.For Water Sual)JI.&iniectionVells: I In addition to sending the form to
13b.Disinfection type: granular the address(es) above, also submit one copy Of this form within 30 days of
Amount: completion of well construction to
where constructed. We county health department Of the county
Form ow-i
North Carolina Department OfEnvircinmental Quality-Division of water Resources Revised 222-2016