GW1-2021-01983_Well Construction - GW1_20210527

For Internal Use Only:
I.Well ContractorInformatton:
Chris Morgan
14:IVATER ZONES-
Well Contractor Name FnOM1l TO DESCRIPTION
3572
ft. ft.
NC tVeli Contactor Certification Number
1S.,OUTEIt CASING Iror multi=cased wens Olt LDM,P .r. ncabla
Morgan Well&Pump, Inc. rRonz To D[AM1tETER THICIwEss hfATERLIL
Company Name +t ft. ft. s tl0 in' sdt2t 1pVr
16.INNER CASING OR.TUBING!eotheirmai closed-too
2,Well-Construction Permit#: NIA _ r•Roat To I DIAMETERI THICKNESS I ATERM
List all applkahle it-ellconstntction permits(&U1C,Cotutq:Stale,lrariance ere) fL ft. in
3.Well Use(check Well use): ft. I In.
Water Supply Well: 17.SCREEN
Agricultural Muni ' aUPublic ntaa TER t TO DIAME SLOTsIZE THICIMWS M1LITERIAI
EL ft. 1.
Geothermal(Hcating/Coolinaa Supply) IIlResidential Water Supply-(single)
lndustriallCommercial DResidential Water Supply(shared) It ft. in.
10.GROUT.
Ition
rn —e'ion PROM TD NATERLIL WPLACEIMENT NX-1`1IOn&AMOUNT
lNon-Water Supply Well: o R. 20 bentonite poured
Monitoring QlRecovery K ft,
T* Aquifer
tion Well:
R Recharge a oG roundwaterRemediation ft
- Aquifer Storage and Recovery t (Salim Barrier 1 SANI)JGRA.VEL PACIt if a Rcable).,
Q ty rltc To I nrATEerAL I ENMP?"MMENTNTUROD
Aquifer Test oStarmwater Dminage ft. it.
Experimental Technology QlSubsidenee Control
Geothenrta!(Closed Loop) QlTracer 20.DRILLING LUG(attach additional sheets if necessary)
Geothermal(Heating(Cooling Return) Other(explain under r2l Remarks} FROM To DESCR PTroat carat trardacss,sol0ractt t r;grata 47A air-)
O Ft. !'S ft. l
4.Bate Well(s)Completed: Well 1Am n/a S fr. �►� ft.
tit i y
Sa.Well Location: 'So ft. ,�C,ft. rx
R4I rtc C.Je&u. . n/a cJ5 ft. Tfo ft. pW h' G
Faciliry/OwncrNamc FacilitylDff(ifapplicable) $(! ft- 00ft, bLe
I
Phya{cal Address,City,and Zip It. ft,
(/�� �-r-y� n/a ai.IZEMAItIcs
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minuteslseconds or decimal degrees: ''3��0IOCey
(ifwCell field,one tat/long is sufficient) j 22.Certification:
LVO t D i
5 �l
6.Is(are)the weil(s)n Permancut or OTernporary Signatum ofCertifjgd Well Conuaciar Dad
Bi,slgmiq dtls,(arm,I hereby cert f&that the trell(s)was(were)constnicted in accordance
7.Is this a repair to an existing well. 13Yes or ONO iith 1Ss1 NC4C 03C.0100 or 151 NCAC 02C.0200 Well Constniction Standards and that a
Ifthis is a ropair,fill out 1710tvn:volt consunction information and explain the nature ofthe copy of this record has been provided to the mil oumer.
repair order 921 rentarix section or on die back-ofthis fora
23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to;pmvide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of~veils construction details. You may also attach additional pages if necessary.
drilled:
// //�yy�am� SUBIVI:i�TAB,HgSTRUCi'IONS
9.TotaI well depth below land surface:_CDW (f ) 24a.For Ail Wells: Submit this form within 30 days of completion of well
F-ormtirhlple wells list all depths TdUrere r rerampla-3 o@200'and 2«1001 construction to the following'
10.Static water level below tap of easing: DLJ (ft.) Division of Water Resources,Information Processing Unit,
if tinter level is above twing,rise-+ 1617 Mail 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
12.Well construction method: rotary above,also submit one copy of this forth within 30 days of completion of well
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 Ivrinil Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm). 3_ --Method of test: air pressure 24c.For Water SupDiv&3niection Wells: In addition to sending the form to
the address(es) above, also submit oriel copy Fof this farm within 30 days of
13b.Disinfection type- granular Amount: completion of well construction to the county"^health department of the county
where constructed.
• I
Fort GW-1 North Carolina Department of Environmental Quality-Division ofWatcr Resources Revised 2-M-2016