GW1-2021-00616_Well Construction - GW1_20210205

y4.:ltION RECORD LqW.1 ForinternatUse only:
..Well ContractorlttfotTnatlon: �k
Chris Morgan 14:WATER ZONES
Rreil Contractor Name FttOAi TO DESCRIF[lON
ft, R. j
3572
ft. ft.
NC lVell Contractor Certification Number is.o �liar multi eased yells OR ZiNER r accrete}
Morgan Well&Pump,Inc. rttont To DtAnsErER THIcIMESs A1AWMAL
Company Name puc
j i6.INNER CASING ORTtIBrtsIG{euthermnl closed-!oo
2.WeU'Constructinn Permit#: 9'%}~t MOM 7o DtAAtE rR TtuctuvFss aZATERIAL
Listall applicable srell conrinrcrion permits(i,,VIC.Caura(:Store.Variance etc,) n• ft. in.
3.Well Use(check-well use):
*]dater Supply Well: 17.SCREE
FROM
DIANIL 6R SLOTSIZE THtCit11ESS MUTER
Agricuittrrai QlMunicipal/Public Giothemral(Heating/Cooling Supply) WResidendal Water Supply'(single)Industrial/Commercial DResidential Water Supply(shared) ia,Gltrlaatl4ll FROM A7ATEIttA[r >iiAIPL1C2AtENTAiLTttODScantOttivT
Non-Water Supply Well: 0 n• 20 R•. bentonite " poured
14fonitoring Recovery
Injection;/e elh
A uife.r Recharge QGroundwater Retnediari on ft, fi
.
Aquifer Storage and Recovery ISalini Barrier 14•SAN1?IGEI, (if a licable) "
Q tY FROAr E-AIPACII
ATCRSALAquiferTest E3iStormwaterDrainage fZ. ft.
Experimental Technology C31Subsidence Control ft.Geothet trial(Closed Loop) QlTraeer 20-DRILL (attach additional sheets if nems )Ocothcmtal(Heatiag/Cooling Return) 1 . Other explain under 021 Remarks) FROM t DESt:RiPTtoN calm,tmrdness satvtvctt tt a alarm s cte)
ft, �� Ct. I red
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4.Date A/eli(s)Completed: Well 1W n(H i1, 1 AP-5 l
Sa.Well Location: v�S % 3 ft. ~
n1a ^ fr, rt.
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L
tFaciifiry/Otvncr iJomc Facility IDm(ifappiicabie) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft.
Z]yJ nia 121.REMARISS
County Parcel Identificationyo.(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one latAong is sufficient) 22.Certification:
6.Is(are)the rteil(s)0Permanent or OTetnparary Signoture of Ccitifikil Well Contractor Date r.
Bi,signing this m,I hereby err10 drat Ilto rtrll(s)teas(were)constructed In accordance
7.Is this a repair to an existing well: Dyes or E)No c'ith 15A AIC4C 01C.0100 or 15A NCAC 03C.0200 well Conatnrction StandosYrs and Char a
1f fitis is a rapah;fill cut]nowt well construction infurnation and evpiahr the nuntra of the copy ol''this mcordhas been proo)detl to the troll ottmer.
repair under#21 remarks seellon cr on lire bank of this form. 23.Site diagram or additional well details:
S.eor GeoprobeII)PT or Closed-hoop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 QW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' SU3fVE TAL Pt lS T RUCTITO VS
9.Total trail depth below land surface-._ �All Wells: Submit this form within 30 days of completion of well
f ar multiple trails list all daptius Tdi�ereni(e runpie-3@200'and 1@100-1KM-Ut I ViTctrdrl+lon to the following:
10.Static stater level below top of casing: , :, x Division of Water Resources,Information Processing Unit,
if tarter terel is abate evsing,rise"r" 6• X 2021 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (iD) is ",;;;;;3(jgn prot.e0jfi{( giftflection Wells: In addition to sending the form to the address in24a
12.Well construction method- rofr7ty DWR Secti&Pve,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.Huger,rotary,cable,direct push,etc.)
Division of Water Resources,16!adterground Injection Control Program,
FOP.WATER SUPPLY WI?LLS OINLY: 1636 Nail Service Center,Raleigh,NC 27699-1636
13a,t raid{;pm) A lYethad of test air pressure 29c.;?or Water Sunniv&Iniecton Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 36 drys of
13b.Disinfection type: granular A-mount. 3 4-z-- completion of well construction to�the county health department of the county
where constructed.
Fong GIV-1 North Carolina Department of Environmental Quality-Division of Water Resouras� Revised 2-22-2016