GW1-2021-06981_Well Construction - GW1_20210505

0IiJL a,uq:rJON
For internal Use Only
1,''Veil Contractor information:
Chris Morgan
"reil Contractor Name s"- '14.ly.h, EONES
3572 t=''� ; / r•Roni To
h'�^ " Ct. DESCRiPTJON
NC 1Yell Contractor Certification Number F
4Y X5 2021 � f=• ft.
Morgan well &Purrip, Inc. a IS-OUTER CASING(for multi-cased sVic OR L
^'`:;�, `vr,1 cur'IT':j ' II FROM TO tNER(ira livable)
CompanyName DWAtETER THtCIINESs
��//�� a r:v +tdIATERIAL
�JV `� 61l8 sd27
2.iV'1l'ConstruedonPermit�: t6.INNERC INGOR PVC
List a!1 app(/cult/e rr2q carstnrctfon penniu(i.e U/C,Cotrnn:State.1'oriance err~) UROAt TUBING( eothermal closed-too
TO DIAN ER TlUCKNL•SS
3,Wcll Use(check well use): f= fr. MATERIAL
in.
Water Supply Well:
Agricultural 17.SCREEN
1nl
-(si0Municipal/Public r•ROAT TO DIAMETER
Geothermal(HCa
fL ttIta SLOT SIZE TBIC[OCSSS AL�TERiAL
o/COoling Supply) Y{Residential Water Supplynge) f'
�Ilndustrial/Commercial ft.
DResidential Water Supply(shared) ft.
Irrigation IS.GROUT
N`on-Water Supply well: r•RonT To
AtATERCai. EAIPLACEAIEA"i•AIET}IOD&AI110U1T
.Monitoring o ft. zo ft.
injection Well: DRecovery bentonite poured
Aquifer Recharge ft. ft.
Aquifer Storage and
Groundwater Remediation ft. ft.
Recovery 01Salinity Barrier 19.SAND/GRAVEL PACIc-(If a ircabic
�DAquiter Test FRoivy To
01Stormwater Drainage ft ATATERLAL F.tLiPLgCFItiEn r nrFt won
Experimental Technology rt.
80cothermal(Closed Loop) OlTra sidence Control
ft. ft.
QlTracer
Geothernal(Heating/Cooling Return ''0 D12ILI ING LOG(attach additio!Otheunder-",) nal sheets if necessary)
r(explain 1 Remarks) FROM To DESCR[[YrJON fmlor etc.)
,lnrdnvss soiUrae
.Date Well(s)Completed: 4 a.1 d ft. cl;t III z
5 ft, i well> n/a S ft. 35 ya.Well Location- ft. O h
n!a U3 S fr. ft. � O
Facd[ry/OwnerNamc T tt $5 ft.
{y �j J,D Facility �rCWh CZSG�
1 1 ��/1.1�i L 1 0 w� O S ft. b.D ft.
�► -��S6vY4 MCI Z4��L ft.
Physical Address,City and Zip ft.
nfa
ft. ft.
coanry --1.REMAxtcs
Parcel Identification\To_(pml
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tf;°Cl'jCld•,ancc�ongissuflicicnt)
.�S.�•Ja to _GO � 22.Certification:
6.Is(are)tiro well(s)
,OX Permanent orI e'=em
0 poral-y Sigttaturc ofC a Iifjt:d Wcll Contractor �` Z
7.Is this a repair to an existing `les or ,. Dat
dr
well; D 2lNo BWill,15,1}signing this•jornr,llterebp rnrrifi••Ilrat r6e ur!!(s)was(tir•ere)constnrcred in accordance
ep is is a repah;jrl(aat known t or airell the r back
fnjnratat(nn and eiplaia pre mantra ojthe c pp of 1 irr rn ord'has ��l p,r L d Nj ��i 'unmet.
repair under 2?/renrarls section or on the Lack ojpris Porn;. C-0-00[Ire!!Caarh erct/arc Standards and that a
S.For rveoprobe/DPT or Closed-Loop Geothermal Wells having 23•Site diagram or additional well details:
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofvellIDe You may use the back of this page to'provide additional well site details or well
drilled: ' ) construction details. You may also attach additional pages if necessary.
g.TotaI Tyefl depth below land surface: J O SUBMITTAL L'�'S T RUCT TOWS
]'-Or'nitrltip(e x eUs list al!deathsJd�erent(eratnple-3 t�i 300 and a@long (`') 24a. For All Wells- Submit this fdrm within 30 days of completion of well
10.Static water level below top of casing: 3S construction to the following:
ljnnterletwiis abovecasbig,:av T' (ft.) Division ofWater ResouredIs,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,AIC 27699-1617
(in.)
ruin 24b.hot Infection Wells: In addition to sending the form to the address in 24a
12.WelI construction method: rY above,also submit one copy of this form wi
(i.e.au-per,rotary,cable,direct push,etc.) thin 30 days of completion of we►1
Construction to the fol[owin�:
FOR WATER SUPPLY EhTLLS OINL y: Division of Water Resources,Underground Injection Control Program,
13a.Yield(Spill) 4;1! 1636 Mall Service Center,Raleigh,NC 27699-1636
IcIethod of test-. air pressure
24c.For Water Sui)niv&Inlection Wells: In addition to sending the form to
£3b,Disinfection npe: granular �z the addresses) above, also submit one co
py of th
Amount: tp/_ completion of well construction to the county healthtsdepartment of theform within 30 dcounty
where constructed.
Foml G:y_I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-2-)-2016