GW1-2021-00613_Well Construction - GW1_20210205

Y V IlL11.1J� li t�auJ`4r•!l10N�tCORD Lqw 1} For Intemai Use Only: .r�.0m�
1.'r"i'ell Contractorlttfannation: 1
Chris Morgan 14.WitTERZoiYES
Wall Contractor Name r•RON TO DESCRIFrl014
3572
fL %
AC Well Contractor Certification Number M K rx uv ur maietaaed ric8s art u[NIM(Iffmallenblel
Morgan Well&rump, Inc. Front ro DUntE1ER TMCMMS nfAT- L
Cumpany Name +t tr. = ft. s t1e ' in, sd2I pvc
('f .16.INNER CASING ORTURING eothermat closed-l000l
Z.Weil'Constructian Permit#: (( rnaat TO DIAhtEtEA rtltCtcNtsss AMTERIAL
List all applicable uull constnictlan pemntts(jr-UIC,Cattmr,State,Varfance etc) iL ft in .
3,Well Use(check.well use): ft. R- in.
Water Supply Well: 17.scREEN
wont To Dlnatarett SLarsrZli THICI#R'ESS hLtTEn1AL
.Agricultural DMunicipal/Public ft ft to
Creathcrmal(Heating/Cooling Supply) I IResidentiai Water Supply-(single) ft. ft. in.
... Industrial/Commerclal DResidential Water Supply(shared) I0,GROUT.-
lniaation FRont To MATERIAL EnIPLACEniENTUETHOD&AMOUNT
Non-Water Supply Well: O R- 20 ft'. bentonite poured
(Monitoring �lRecovory
Injection ih ell:
Aquifer Recharge tt ft,
q S QtGroundvvater Remediation _
Aquifer Storage and Recovery iSalini Barrier 29 S iGRAVEI,3'ACIC fa Iieatrle}.
ly FROAf TO ntATMTAL ensrucmcrxrr+s>Tao
ft-
Aquifer Test OStormwaterDminage fk.
Experimental Technology E]iSubsidence Control it, tt.
Geothermal(Closed Loop) OTracar IS DIM Mr-LOG(attach additional sheets If necess
Ccathomial(HeatinglCooling Berton) ; . Other explain under 021 Remarks) Fnoas To D CAirrt rON eotar,tmrdacu, oracle t a iristzq eiat
('j ft.
4.Date Well(s)Completed: � �� � Well IIM#0/a L�..0 i?• '��1 n• � �-��
�WeltLocation-: /w ft. ft
j6 }} Y n/a ft ff_ t l
FacilltytOwncrNamc Facility iM(ifapplicable) ft. ft.
I'lixemul Address.City,and Zip ft. ft
n1a 21.REMARICS
County Parcel Identification Vo.(PiN)
Sb.Latitude and longitude in degreeslmiauteslseconds or declmaldegrees:
0tweil field,one lot/long is sufficient) . 22.Certification-
6.Is(are)the wcll(s) ermaaent or OTetnporary Signature of Cortiilika Well Contractor Date
By signing this fonu,I Iterrby certth that the nrll(s)was(weir)constructed In accordance
7.is this a repair to an existing well: Qilles or ONo oidt 15A AVC 02C.0100 ar 1S.4 A'CAC 03C.0300 Well COOSi171clion Standard and that o
if flits fs a repair,fill ant ktmwn well constritcdon infanttatfon and explain dre natarc of tiro espy of this record has been pnrufded to the rtix!!1 Sumer.
repair under t.31 remarks section or out the back of this form. 23.Site diagram or additional well details:
S.For GeoprobeMPT 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 1 OW-1 is needed.Indicate TOTAL NUMBER o£wet � l ��rruction details. You may also attach additional pages if necessary.
drilled: 1 rI tN �L'BtMTTAL LrgSTRUCTTO1VS
9.TotaI troll depth below land surface: (v� n.For All Wells: Submit this farm within 30 days of completion of well
Farinulttple walls list all depths tjdLetaiu(example-3@200'and 3@100(l �� Q onstruction to the following:
10.Static Slater level below top of casing: }Il(�Ull%ivision of Water Resour'cos,Information Processing Unit,
Touter tat=et is agave casing,use"+' i R Sedjpil 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) C)W24b.For Infection Wells: In addition to sending the form to the address in 24a
rota above,also submit one copy of this form within 30 days of completion of well
t2.well construction method; rotary construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOP WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield air pressure 24c.For Water Supply Inlectl6n Wells. In addition to sending the form to
(„�prtt} �►"Yietltod Of test. 1;
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection t)pe: granular Amount: completion of well construction toy the county health department of the county
where constructed.
Form G1V-1 Nor%Carolina Dcpattmcnt of Enviroamenlal Quality-Division of ivater Resources Rcviscd 3 3»-2o t6