GW1-2021-00619_Well Construction - GW1_20210205

W—EL MON RECORD(QW-1 For Internal Use Only: .. .. ,�.
I-Well Contractorh armation:
G
Chris Morgan 14.ti`ATER ZONES
Well Contractor Name PROM I TO DESCRIPt1piV
3572
fL fL
NC tYeii Conuaetor Certification Number 16..OUTER CASING fror multi-cusad rvelLa OR LAVER a it
b7t cabtem
Morgan Well&Pump, Inc. oMl TO DlAtrtBTER' TelctavEss MlATERIAL
Company iVante
}! fit. G fit. 8lt0 din• sdi21 pvc
16.1NNER CASING OR TUBING(eathermat closdloroi
2,Well'Construction Permit:.__ IC? ` ;17.
TO DIAalercit THICKNESS n�tTsRIAL
List all applicable a211 corrstntctlan permits 0 UIC,Cator(r,State.Yartmice,etc) EL ft in.
3.tVcEl Use{cltecli well use}; fL R. In.
WOter Supply Well: REEN
A cultural TO IAtt ETER SLOTStZe THIC-1 &SS IIIATERIAL
0MunicipaliPublic ft It. in.
Cieorhemmal(Flenting/CoolingSupply) eResidenlial
asidential Water Supply'(single) ft. tt, in
�Iindustrial/Commercial Water Supply(shared) III.GROUT.
irrigation fR0111 TO l2ATEttItr,' R1v1PL.CM=-NVThILTHOD&AMOUNM
Pion-Water Supply Weil: o fL 20 R• aentenite poured
Monitoring Recovery
Injection ell.-
Aquifer fit fit.
Recharge ft. ft
g �Gmundwater Remetiiation
- [Aquifer Storage and Recovery EllSalinityllarrier 19.SAND/GRAVZrI PACK ifa Itwbtc).
FROM TO MIATEaiAL4 EAtpL7—MIRMNIFTHOD .
Aquifer Test DStormwater Drainage ft
Experimental Technology DiSubsidence Control fit. ft.
Geothermal(Closed Loop) QlTmcer 20.DRnJ AVG LOG(attach additional sheets if necessary)
Geothermal(13eatinglCooliogReturn) DOther(explain under#21 Remarks) FROMI I TO DESCRIPTION color.hordaeu,soluroct,n a8raios'tzaeta]
6 ft. r
4.Date Well(s)Completed: 1.--7^V Well mm,n/8 tj fit ft. v wn
Tlvo))
ell Location: R' � i eq,%*,
)h 55 t1/3 fit. fit.
FacilitytOwncr Namc Facility ID!(if applicable) ft. fit.
Physical Address,City.and Zip ft. ft.
r 21.RrVIARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattang is sufiicicat) 22.Certification:
i
6.Is(are)the wall(S) Permanent or O i emporary Signnturc of Certift?ii\Vell Contractor Date
BS>signing[Ills for n,i herby certh,[itat the vtrll(sJ was(,em)constructed in accordance
7.Is this a repair to an existing well: Dyes or n No t ith 15A MUC 01C.0100 or 15:i NCAC 02C.0200 Wl Construction Statdmds and that a
if This is a repair fill art dwowtir well consintction infannation and explain time nature gftho copy of this record has buen provided to the hall owner.
repair under n21 remarks section or on the backofthisfornt.
r � /{� Site diagram or additional well details:
S.p'or GeOprobe/DPT or Closed-Loop Geothermal Wells FaWr s��V L» a may use the back of this page to;provide additional well site details or well
construction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:-' I t �tS X 5 2021sit-gBGTTti_.?iL'STR€C-1I0NS
9.Total vrell depth below land surface: 14 rc) 1,_3Fein&11J*br All Wells: Submit this fort within 30 days of completion of well
or nut/ripla wells list all depthstjd{lJerent(erantpia-3(la 200'aiid 2�06V1 R Section construction to the following:
10.Static water Ievel below top of casing. � 13 (ft j Division of Water Resources,Information Processing Unit,
V"wvvier teval is above casing,use 1617 it/£ai1 Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: {in.} 24b.For injection Wells: In addition to sending the form to the address in 24a
rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield air pressure 24c.For Water Suonh'�iniection�Wells: In addition to sending the foram to
(gpm)� Method of � g
the address(es) above, also submit oat copy, of this form within 30 days of
13b.Disinfection tree: granular Amount: p '� completion of well construction to the county health department of the county
where constructed.
Fonn Gtv-t North Carolina Department of Environmental Quality-Division oflVater Itmourees Revised 2 22-20I6