GW1-2021-00596_Well Construction - GW1_20210205

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I-'Veil Contracrorlfifermatlan: For Interne]Use Only
Chris Morgan
Well COmimemr Name
3572 Fay TERZONFS
70 DES LOIN
NC Wdl C°naaclor Cenificndon Numbet R ft.
Morgan Well&PUM p, Inc. FLo
15.OUTER C or maldcasad
CompallY Nana` FRtM1 TO 70 Hells OROL1A1EfER L@lnR fa neabla)
2.Well Construction
7 ♦) n, 6 n. a[/e in• THIC[OIE,gS uA7aMAL
' r`Ll2 (/
Lirr all applimide ue/lm'"ruction a 16.INNER CASING OR77fgING PVC
Permtr( U/CCrui,State.fannnce ma/ FROhl 7O (eotherm sdm a,timed.1oo _
3.Well Use(cheel(well use): R it. DIAIII Ell TH)CItNEbs ItsTpRI+D,
is
Waler Supply Weg: R
R la
Agticultival 17.S
Geothermal(H CREEN
aa I_public FRoat
tmg/Cooling Supply) Residential Water Supply R TO R scot SUErRiaasFss Bfa
IndustliaVCommercial If-�Municipal(P I-�' PP y(single) 1a
Iai ation QlResidcntial Water Supplyft. n• in,
(shared)
Non-Water Supply Well: 1&GROAT
PRAT
Mtion Lf
rig rr---7r'' atA7ERLtL ELACEhm Injection ell: Recovery, a R R hip NIAMMOD&AMOUNT an . eanianae
poured
Aquifer Recharge tom, R n.
Aquifer Store a DGmundwapar Remedation R• It.
g and Recovery I-^�,Salini B 19.SANIyC
Aquifer Test ry Barrier RAVEL PACK If neabic
Experimental Technology Stormtvamr Drainage �OM1z TO MATERIAL
11t!,,[]I n. R eamracnatsNr hta7xoD
Geothermal(Closed Lope) 0SUbsidence Control
07Tmcer ft. ft.
Oeod"'re"(Headng/COOlin
Retu(!rn) ' Other(ex lain under P21 Remarks) proMill Li.I1vG LOG omachnddidaaol sheetsifnemss )
4.Date Well(s)Completed: C �� DESCRi oN talon�� WeII IDN n�a 11 R R hman es*.mlamchh t• in ztra elel
Sol.Well Location: •-'��-- It. d R. C D•
R U/ey,t fLpc�_
e/ K4r•r n/a od l O R.
po I1y"I" rNamc�� 96 n• �6
Fani ny[Do fapplicable) ft• r lilt C.rC&A
n.
phys al Addrers pry IZp o K �� Mi»/`o 1 d ii iG R
County , `qv 21.REMARII{,y
Sb.Lutitude and longitude in degrees/minutes/s toads or decimal Tin.degrees:
(ifwcll field one I'vi ng is sufgcfcnt) unl deggrees:
22.Certification:
6.Ie(are)the well s Ope i1
O rmaa®[ orTemporarv, 7 /ip
s bTal ofCcn1fj6d Iv ell Conham°r 7,!s ibis a repair to an IL�7 Q I` Dale
jfbit rc a rnpair,fill out knouie�Srh,,.(/gcy rcrion rnfonrmr or and mlain the nainm of iaPl r SA i'C4CO/b n011I Sderl AC 2C Darner.
uilh ISd XCdC 03C.I he b 13A y flmt lie uc' 1v=(ware/mnsin+cled in aem,dance
mpair under:3/mn+arLrse den oron the bark oft/risf°m1. iC 0_C.0_60 Well Conslrnciia,Sfanda+dr and rlmr o
S.For CeoprobeJDPT or Closed-Loop Geothermal Wails basin 'Sue dagram or addtlonor well details:
c°psimctipn,only 1 G}l+-1 is needed. Indicate TOTAL g de same You may use the back of this page t°provide
dnlinl: ' 1 N3IMBER ofwclls< ConstrvctioD details. You ma}'also e10 additional pages if well
site
detis Orwell
9• at,
hell depth hdow land surface: 6 \v�i� SLBMITI•AL Dgy^gUC�Ns
Pornurlffple ua!/r list al!depilu/fd(JJemrn(emmple-3Q300' (f')1` 24a. For All R'ells•
Q constmctio� n t �)osg it this form within 30 days of completion of well
10.1
0.Suit,
)t ater level below rap of casing; (�
f Hers lcre!tr abate raring,roc•'}^ ( nn
t�V Division of Water Resources,Information Processing Uni4
31.borehole diameter. 6 1617 Nfait Service Center,Ra]ei t,NC 2
_�(iD.) �Stp�\On g 7699-1617
12.'Vell construction - rota "'D�,tdR 246.F0;Far lule W"S' in addition to sending the form to the address in 24P
(Le,Sager,m ma pO R elcJ - ebov also submit one copy of this form wi[Iva 30
Se lary,cable,d6cr m e,
construction to the following: days of completion of well
FOR WATER SUPPLY WELLS ONLY: Division PI Water Resources,Underground
1636 Mail SeW"'CenterRaleigh,PIC 2 76 9ection Contra)
1 633 6 program,
13a.Yield(wpm) 'Method of test: alr pressure
2de For Water Su It•E!n-ectiaa Wells: Ta addtioa to seadimg the Farm to
136.Dis)afecdoa ripe: granular the addess(es) above, also submit one co of this foram within
•�_ Amount: 6'l. completion Df well coasnuction to the couny health d l wlhm 30 days of
where constvetcd. b' deplete Of the county
Fonn oil'-1
North Carolino Department ofEaviromaenlal Quality-Division of Water Resour
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