GW1-2021-03015_Well Construction - GW1_20210527

—WELL CY/V rl}r V19STRUC 'gO RECORD(Q ) For bterfial USe Only:
1.Welt Contractorllnformatten:
Chris Morgan 14:1VATERZONES
Well Contractor Name rRONi TO I DESCRIPTION
3572
fL ft.
NC Well Contractor Certification Number Ig,.pER G tfor mviti cosed wells OR LINER rf. t#ca67o
Morgan Well Pump, Inc. rRoht Tn DIAMETER THic[tNESS hfATEtua4
Company Name +1 B' 1 ft` 6118 1q` sd2t pvc
.16.INNERCASING OR-TUBING(geothermal closed-loo
2.Weti-Construction Permit#: ,,,,)) rRoht TO DIAMETER THICKNESS I MATERIAL
List all appllcahle well constnrction permits(i.c.UIG Court(rt State.Varianca eta) ft. ft. in.
3.Well Use(check ivell use): f4 fL la
Water Supply tNell: 17.SCRRsEN
GM TO DIANtETER SLOTSME THICKNESS MATERIAL
Agricultural DMunicipal/Public IL it In.
Geothermat(Heating/Coaling Supply) &.42psidential Water Supply-(single) it. ft. in
�Dindustrial/Commercial DResidential Water Supply(shared) 18.GROUT..
Irrigation FROM TO INTATERLt.[. ENIPLACENIENTBIrTHOD&AMOUNT_
Non-Water Supply Well: o fL 20 ft,
; ;, bentonite poured
Monitoring Dlkecovcry ` ; fL ff,
Injection Well:
ft:
Aquifer Recharge oGroundwater Remediation ft.
- Aquifer Storage and Recovery ISatini Barrier 19 SAND/GRAVEL PACK ifa" licable).
ty FRONT TO NTATERTAL I ENTPLACF.NtENTN1ETHOD
Aquifer Test 0stosmwaterDrainage fl• ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed loop) QlTracer 20.DRUTLLINC LOG(attach additional shoots If necessary)
Geothermal(HeatfnglCoolingReturn) Other(explain under val Rerneiics) FROM To DESCRt Orr color hardnemsolltrachit c.erarasimcte.)
{0— + �it. fc. -r�-
4.Date Weli(s)Completed: J'1 1 < t�reil Iebr`fi/a ft. S it. n
So.Well Location: S'ft.
T)enAi 5 t�G& ey n/d ft. 6,6 ft. n X-
Faciliry/OwnerNamc /-- JN
-��+FacilityID-(ifapplicable) U ft. �j ft• 1r
t it 4 Cr ,� ft. ft
Physical 21
Address,City,and Zip 1 ft.
kO A_. NoeSm"- .REMARKS �..
County Parcel IdendfimelonNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/secands or decimal degrees: 1na
(ifwell field,otneelotttllonng is sufficient) { )/�r� t t !.+`•,22.Certification: O
W {Cifvjts•0 ; C1:0
6.Is(are)the well(s)k ermaricat or OTempomry Signature ofCcrti NVcU Contractor Datj
B)t signing dar fonn,1 hereby cord,/,that the uall(s)was(Irene)consinicted in accordance
7.Is this a repair to an existing well: DYes or n NO Will ISA N"C 02C.0100 or 139 NCrIC 02C.0200 well Construction Standaevir and ilia$a
TKris Lv a repair,fill out known ivell constnucfion infannatian and etplain file nature of the copy of this record has been pruvided to ilia wall owner.
ropair under'421 remarks section or an the back of thisform 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-�is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' 5SL-3hflTTA� R+STRi3C'siOPIS
9.Total well depth below land surface: 16 24a.For pill Wells: Submit this form within 30 days of completion of well
Far nratrfple$cells fist all depths Jd�erenr(esnmple-3@200'mt 2Q1 UDC construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,information Processing Unit,
If%rater level is abate rasing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 CI 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 Iforrn 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ a.4 air pressure 24e-For Water SuT) lv&Inlectiort Wells: Itt addition to sending the form to
-���,,,,Method of .� g
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection ripe: granular Amount: �/ completion of well construction to the county health department of the county
where constructed.
Font GW-1 )•forth Carolina Department of Environmental Quality-Division of hater Resources Revised 2-2.2-2016