GW1-2021-00588_Well Construction - GW1_20210205

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1. Well Contractor Information:
Chris Morg
lrvl MACML"dt u5G Vllly:
14. ATER.ZONES
Well Contractor Name
3572
i' C well Contractor Certification Number
Morgan Well & Pump, Inc.
Company Name {
2. Well'Constructian Permit#: `Z(G S
List all applicable well eonstnuctian permits (i.e. WC. County. State. Variance, etc)
3. Well Use (check well use):
Water Supply Well:
JAgricultural
Geothermal (Heating/Cooling Supply)
Industial/Commercial
' Irrigation
Non -Water Supply Well:
Monitoring
DMunicipal/Public
w»' Residential Water supply (single)
1 Residential Water Supply (shared)
Recovc
FROM
TO
R.
DESCRIPTION
IS..ODTER,CAKING (ror mula-cased wells) OR LINER (Ifnp 11 Uto)
FROM
+1
ft.
TO
151 Er.
1 ca
pvc
DIA!I ETER TEflaGlESS MATERIAL
611E 111
in.
d21
FROM
TO
DIAb1ETER
THICKNESS
MATERIAL
R
ft.
in..
ft.
tt.
lo.
Injection 'VI/ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experirnental Technology
Geothermal (Closed Loop)
nacothcmlal (Heating/Cooling Return)
4. Date Well(s) Completed:
Well Location:
ere kh
`4 ro� gamc
odd s
u
Ili
Physical Address, City. and Zip
County
DlGroundwater Remediation
QiSalinity Barrier
DIStormwater Drainage
pi Subsidence Control
QDTracer
nlOther (explain under *21 Rema
L well Ilr# nla
nia
Facility TDm (if applicable)
C�c�rr( NG Z8o
nia
MT: SCREEN
FROM
ft
ft.
10. GROUT FROM
0 R.
TO
R.
DIAMETER
SLOT SiZE
THICKNESS
MATERiAL
R.
TO
20
a1ATEtUAL.-
bentonite
EMPLACEMENT METHOD & AMOUNT
poured
Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3 - �� 1 PI — `AO . r7c <1 o
6. Is(are) the well(s)
t or [3ITemporary
7. Is this a repair to an existing well: [Yes or L
Tibia is a repair, fill awl known well constnheton information an
repair under #21 remarks section or an the back of thisfano.
ft.
ft.
R.
R.
19. SAND/GRAVEL PACIC(if applicable).
OM I To
MATERTAL
EMPLACT RENT METHOD
rt.
R.
20. DRILLING LOG (attach additional sheets if necessary)
3 cll.
go ft.
2 94 l 51t. bravo, rock
/ O. lab
R, ft.
21. REMARKS
TO DESCRIPTION Nolo, hanlaess, sotliracic !lye. etalo size. cicl
�a('atw►-1 dirt
IS" ft.
35' R.
Q`Q R.
brawin. c-at)C / ax✓d1
rt- 1 .Sltl'lLl
22. Certification:
' I k t/t'Go/'1_i-
Signature ofCcrtif6d Well Contractor Date
By signing this foram. 1 herby certh that the well(s) was (were) cansrnrcted in accordance
with i5A NCAC 02C.0100 ar 1SA NCAC 02C.0200 Well Constreciian Standards end drat a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
R. For Geoprobe/Fl?T or Closed -Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, only 1 G'it-1 is needed. Indicate TOT 11 construction details. You may also attach additional pages if necessary.
rt
drilled: ' . A � l V C D SUBMITTAL Pt IS T RUCTIODIS
T l 1l d th below land surface:6 Ob 9.ota (f) Z4a.F All Wells: Submit th.fo
w
No
explain the nature of the
we ep a ow an r M or a s: is
For multiple wells list art depths ffdlereat (example- 3 a(120(1' an 3CO 6 2021 construction to the following:
10. Static water level below top of casing: i .
ff warer feral is above casing. use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: rotary
auger, rotary, cable, direct push, cue.
rh a;.,; lion ProcesaiRdifAit
DWR Section
FOR WATER SUPPLY WELLS ONLY:
13n. Yield (gran)
Method of test: air
pressure
13b.Disintection type: granular Amount: (t�O�
within 30 days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
2Ab. For Infection 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
construction to the following:
Division of 'Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Snooty & Iniectitin Wells: In addition to sending the form to
the address(es) above, also submit' one copy of this font within 30 days of
completion of well construction to Ithe county health department of' the county
where constructed.
Font OW-1
North Carolina Department of Env'
ental Quality - Division of Water ncsoures
Revised 2-22-2016