GW1-2021-01595_Well Construction - GW1_20210419

MMMIL e.;UNST TTVU0N RECORD(GWI 11
L Well Contractor information: . ........,
For Intemaluse Only: • � .. -" • �" "
Chris Morgan
14:WP.
)Yell Contractor Name TEItZONESM- 01I TO DESCRIPTION
3572
NC Well Contractor Certifiarion Number ft" R•
Morgan Well d:Pump, Inc. 1$•oftcaslNO rormniti-cnsed'tveils ORIiDtER r name)
FROM TO DIAMETER THICKNESS iVIATERIAL
Company Name +1 ft. , ft. 6118 i°• sdt21
'Hpc�f live
2,Well'Construction permit#: • /�J 11� ©�Z� 1 rR INNER CASING OR eutherma(dosed-loo
FROM TO DIAd1ElER THiCtCNESS MATE[tlAl,
List all appllcahle well constrction permits(i e.UIC,Cotaur State,NariancQ etc) 2 R, in
3,Well Use(checl:►vell use):
i0.
Vi/ater Supply Well: 17.SCREEN
8Agricultural DMunicipal/Public FROM TO DU►DiE1ER SLOTSIZE THICIOCESS hL
0cothermat(xcatingfC001inSupply) re ft rn
g residential Water Supply�(single)
Dindushial/Commercial ft• tt. in.
_ [ilResidential Water Supply(shared)
Irrigation 10.GROUT.
Non•Wuter Supply Weli: rRora To arATE[ttAt EhtPLACEntEn-r nirraoD&Antoun�
0 fL 20 ft• hentonite poured
MonitoringQlRecovcry
Injection Welt: fL ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery []ISalinity Barrier i9.SaPtD/GRAVEL PACIC(if a liable)
Aquifer-rest FROAt QlStorrnwaterDrainage ft, TO MATERIAL EatMdCPNIEhTBIFT6oD
Ft.
Experimental Technology ElISubsidence Control
ft. ft.
Geothermal(Closed Loop) Offracer
20.DRILLING LpC(attach addinoaal sheets If necessary)
Oeothernrai(Heating/Cooling Return) : Other(explainunder-021 Remarks) FROM TU DESCRIPTION color,hnrd css.solarodt! c,etal- ate.)ft. ft. •
4.Date Wells)Completed: Well IDR NaMe
�rotai,. �jGZ--
5a.Well Location: ,G S" fe. •�t�0 it.
nla
F11cility/0tvn Namc Facility iD",(ifapplicabie) ft. It,
y3o8 '
�if/QodG✓eck.- G n G%,,mod„4-o it. ft.
Physical Address:,City,and Zip
pia Z q:;7� 21.REMARICS
County Parcel ldcatitication No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees —,;^•1; )' �;t e r rY',Oi) .
(ifwell Geld,one lot/long is sufficient) -,•,e,
3� q�f"V s • �O
22.Certification:
PI :1 r"
6-Is(are)the well(s)0Permancat or OTemporary Signature ofCoA��d Well Contractor
�C 2dZ
Dale
7.Is this a repair
BV signing this form.1 hereby certify that ilia nil1(s)tvns(were)consinicted in accordance
T(dris Ic a repairfill m 6nown rocll cons o an existing well- CS Or n No with 15"NC4C 02C.0100 or 15.1 JI 02C.0200 Orel)Construction Staodarety and that a
, inreti in infonnatlan and etplain Ilia nuntre of ilia ropi,of this record has been prutided to the well owner.
repair under T21 mntar$•r section or on the back of thisforni. •
23.Site diagram or additional well details:
G.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I `
9. SLBiMTTAL Ln1S a RUCTIONS
well depth below land surface:_ 7 U (f-) 24a.For All Wells: Submit this form within 30 days of completion of well
Forr multiple
i tfple walls listst all depthsd tfLerern(ernntple-3@200'mtd 2Qn IUD
construction to the following-
If
it Strafe l is ab tv casing,
helots top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if enter fare!is abort casing,rise"-i-"
1617 Mail Service Center,Raleigh,PIC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 242
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY% LL5 ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Nail Service Center,--Raleigh,INC 27699-1636
I3a,Yield(gpm) Method 0f test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
granular the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection tti lies 9 Amount: completion of well construction to the county health department of the county
where constructed.
Fort GW-1 'North Carolina Department of
eP Quality-Division of Natcr Itesoun:es Revised 2-32-20I6