GW1-2021-00601_Well Construction - GW1_20210205

COI8l9 GW-1 FmaUse Only.Conttactorfnfor¢aRn:
-- .
Chris Morgan
R40Cammemr Nome 14.IV •r y(1 _
3572 ,us IL TO nFscwrrloN
NC Well Contractor Cmifiaaton Numb.[ fL 6
Morgan Welt& PU rap, Inc. eROAl RCASING form DIA111sad mUs OR LINER [CumPany Neale FRO,It 7'O DIAMETER r°)
+t R. / T�efwFss HATERIAL
R• 6118 in.
2,Well Conslructian Permit tit Y �(l( Q —�L��y 16 INNER CASING OR TU __ sd21 we
List ol(oppl(rnh(e uzOronrrrtrctlaapnrtn rr FROat TO (eothermal clMed.lao
( UlC,Camrlr.$Ia(S a'artnne4 eIG) DIA6IEfER THICKNESS atAT1;Rlq(•3,Weil Use(cheelt well use): R. In.
Water SuPPIY Weil: R R la
Agriculttual n.SC12EEN
MunicipaUPublic FROAf TO a-rE¢ Iza
Oewhermal(Hoa[ing/Cooling Supply) It. ELM S
CL THICtN•.SS M1LI7ERIAL
IndustriaUCommemiai ®FRcsrdendal Water supply
QlResidential Water Supply(shared) ft.
It In.
hti anon 7D.GROUT
Non-Water Supply Well: sRDat TO
Monitoring I--7, a ft. atA��f ga1PLACEMaHr M1.?Hon&AntOunT
ejection Well: L_PRmovcry 2D It,tt bentonee P.amtl
Aquifer Recharge a'
DGmundwater Remediation ft. R.
Aquifer Storage and Recovery
Aquifer Tes[
QlSaldnity Bander IR SANDlCRAYEL PACIC fa lathk
soar ro
[Il&Ormwater Drainage MATERIAL mrI CFAIEm.ANTarETHOD
Experimental Technology II-�-''�I,, R, tt.
Geothermal(Closed Loop) I_PSubsidence Control
Geothermal(Heath CoDlin Re QlTmcer20.g Imo) Othw(explainunder 2l Remarks) FROM
DRILLINT LOG(°Rechaaddiflaw ON ev°io nt )
FROa1 TO
4,Daic'Veil(s)Completed-.. "ZL Tt Zp R. �*.+°Iomrah Senia ttra elel
' well rat}Na
Su.Well Location: �— Zo it.
iS s a.
t"tabil �
_LlrrS{'4 mi" n!a 6S a• C3L:�c/
Focrhry/Orvncr Name— —i�V�y fL rC rc- }'
R.
2 66 Facaily IDa(tf.pplipbl.) R.
G� l t ft
Physical Address City and Zap it
G' ?C6�n It. ft
T� r
County 6 W j 2L REMARKS
Iu Pamol Ldcodfication No.(PIN)
(if Latitude and longitude to degrees/mdmutwiseconds or decimal degrees:
(ifWell
{Rc14 on. Vlan is sufticic
tg nt) of
!s q? or2 rJ� 22.Certification,
J W l:/�C �1�%�.f1
6.IS(ara)ttlewol!(s)0Parmanc¢t or oTemporary q' (
s t,m°mie ofCmtfjlHd lVcli contractor
7.Ia this a repair to no existda w G Date
Dyes or XGNo Al'signing this famr.I hembj'<°rcify Isar,due ual!(s),ve,(were!Contracted on
accardmice
PcPai is a repair,fill cut/morn well constmuiart(nformot(on and explain the nature ofrha mPJ'ojlbit mcordhas been pmvidv�l m the uefl mvner.
u'ilh 1SA A'CAC 01C.0100 ar ISd NCAC 01C.010a We11 Caavlmelian Slatrdardr and dmr a
rnpair murder g11 r e"'a"s secllon or on the bad-ofibisfomr.
B.For GeoprobelDPT or Closed-Loop Z3,Site diagram or additional well details:
conslmcR y top Geothermal Welts having the some You may use the back of this page m provide additional well site details or well
on,only 1 01V_1 is needed. Indicate TOTAL NUMBER of wells
drilled: ' 1 ctioa details. You may also attach additional pages if necessary.
9.Total"'ell depth 114110w land surface: ? RECEIT'TAI.INST TIONS
Parrmrl(Iple uel(s listalldrprly lfdpera,v(wnnipfe-3(al?00 and1Q1007 (� �O• For All Wells: Submit this form
/ ��Eohctruction to the fallowing: within30 days of completion of well
10.Static water level belOW rap of casing: L 0 }}��
Pnater lard a aba,van ng.use'•+- �ssin9 Unbivision of Water Resources,Information Processing Unit,
11.Borehole diameter.• 6 •'"'�nR$gCt10n 1617 Mail Service Center,Rnlei h,NC?
�W g 7699-1617
24b.For injection Wells.
("a Well construction method. rotary above,also Submit one co oaddition
this farm sending
wii d�30 da^"to the address in well
(ix.auger,rotary,cable,direct push.etc) construction to the ftllowi FY days of completion of well
FOR WATER SUPPLY WELLS ONLY: Division of'Water Resources,Underground Injection Control Program,
130.yield(- 25' 1636 Mail Service Center,Raleigh,NC 27699-1636
°pat)—�_ Method of test: airproasurs
24c.For.Water Suoaly E inde e jj u ;
In dd136,Disinfection ape: the form to
granular the addresses) above, also submit one copy of this ofonn within 30 days of
--�_ Amount completion of well construction to the county health department of the county
where constructed.
Form GW.1 North CamPni D
.pwmrrnt°FEnvimnrvenry Qtmlity-Division oflYamr Resour,.s
Revised 2-2-1-2016