GW1-2021-00586_Well Construction - GW1_20210205

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I.Well ContmctorInforrnation:
Chris Morgan 14:1VATERZONES i
%real Contractor Name FROM I TO I DESCRUrnoN
3579
fL ft. �
AC Well Contractor Certification Number IS.-OUTEP.CASM0 Mar Wed svcttst f3R Z iNER F: rtcabtc)
Morgan Well&Pump, Inc. FROM TO Dtr1M11ETER THICI4YESS MATERIAL
Cumpmiy Name +t ft. fr. 1 61tg in. sdrzl live
�1 �i�0 16.1NNER CASING 0R TUB ING('eathermal ciased-too
2.Well'Construction Permit#- o rRoat To I DLdbffiTCR THICKNESS I az.ATFRIAL
List all opplicahte u211 coarinrction permits 0 c.Ult.Cotrmr.State.Variance,ere) in..
3.WeIl Use(chedcwell use): ft. ft. in.
Water Supply Well: 17.SCREEN
moat I To I DIADIBTER SLOT s1ZG I TtrfCIQCE55 I MATERIAL.
Agricuituml OMunieipallPublic ft ft tn:
Geothermal(Heniuug/Cooling Supply) WResidential Water Supply-(single) ft. ft. in.
'IlndusMallCommercial DResidential Water Supply(shared) in GROUT
hrigation MONI I To I MATERIAL I rNIPLACENIENTa1L•Ttton&AotouN'T
Non-Water Supply Well: 0 ft 20 ft.. bentonite' poured
(Monitoring DRecovery tt. €t.
Injection Wall: ir.
Aquifer Recharge OGroundwater Remediation
19 SANDIGRAVTLPACIC ifs licabie).
Aquifer Storage and Recovery EllSallnity Barrier M&I I To I NA't'rat7AL EntrtacM. IENT t ssrmmoa
,. Aquifer Test OStorrntvaterDrumage R• ft.
Experimental Technology Qisubsidence Control ft. ft.
Geothermal(Closed Loop) 01Tracar L 20.DRMLING LOG(attach additional sheets Ifnecessary)
FROM TO DESCRIPTION color.hnrdoess soiltrocltt\ e.:.rain47A010
Gcathcrnuat(Heating/Cooiing Return) �"_ Other explain under�21 Remarks)
t © ft. ?,A It. e�t
4.Date Well(s)Completed: t 0-I Well ID#nta �� p' �� it' lb wh OCK
5n.Well Location• rr. ?C> n' '>)Ve_�<kYtz-Yut Fc�
nla ft. ft.
t'acility/0}yppx � ' � Facility iD�(ifs pliwbie) ft. ft.
BUJ ijt7"�C•� ft. it
Ph lcal Address,City,and Zip ft. D'
n1a 1 21.REMARKS
County P=cl Ideatification'No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if well field,one While;is sufficient) 22.Certification:
6.Is(are)the wou(s)OPermancut or OTemporary signature ofCcrtiff d Well Contractor Daie
By signing this for tr,I hare6y c 66,that the wall(s)ims(mere)constructed In accordtntce
7.Is this a repair to an existing well: Dyes or <+ Wilt 15A AVC 01C.0100 or 13.1 NCAG 02C.0200 Well Construction Standards and that a
�No
TINS is a repah,fill0ur known will constriction irllonnotirnt and mplain rise nature of the copJ'of this record has been providW to the well owner.
repair under#21 ramaris section or on the back of ttisfornr. 23.Site diagram or additional well details:
S.1:or Geoprobe/DDT or Closed-Loop Geothermal Wells having th Y ut�e the back of this page to provide additional well site details or well
construction,only 1 QW 1 is needed. Indicate TOTAL IRIMBER o �w 9� o details. You may also attach additional pages if necessary.
drilled: ' /�� L'BMl ii'I{ TA-I. D1STRUCTI
j4PlS
9.Totnl tyeii depth below iand surface: FEB .F EB(. 4 dr All 4i'ells: Submit this!foam within 30 days of completion of well
For multiple melts list all depths ijdVerem(example-3 r1t 260'and 2(a11001 constructs in a following:
9e fwr,,3tio Process►ng`M
10.Static water level belaiv top of using: T� ��edlon Dhision of Water Resources,Information Processing Unit,
if tarter let a1 is above casing,rise"+" 161'7 i l-ail Service Celiter,Raleigb,NC 27699-1617
11.Borehole diameter: (in.) 24b.Nor Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.1Veii construction method: rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VVT,LLS ONLY: 1636 Mail Service Center,1-Weigh,NC 27699-1636
13a,Yield(yplll) YeUlod of test: air pressure 24c-For Water Sunnly&iniection'mtirells: In addition to sending the form to
the address(es) above, also submit'one copy of this form. within 30 days of
13b.Disinfectionr►lie: granular Amount. G7Z" completion of well construction to the county health department of the county
where constructed.
Fonn GW-t North Carolina Department of Buvironmenta5 Quafily-Division of-water Resources[ Revised 2-22-2016