GW1-2021-04252_Well Construction - GW1_20210419

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For internal Use Only.2,tti'ell ContractorFltformatfon: �. ... ....
Chris Morgan
IVell Contractor Name 14.tV9TER 20NES.
3572 M. M ft. TO DFSCRut[Y0'V
NC Nell Contractor Certification Number R. ft.
Morgan Welt&Pump, Inc. 11s•O rMit CA5aNG for multi-cased r
Company\'amc FROn! TO DLUIETER ilcablo
+1 R. T�ClQIESS MATL•RIAL
ER
ft. 61/8 in.
2.Well'Construction Permit#: 3�3 �� 16.INNER CASING OR TUBING(eothermAt closed loo live
Ulf all appilcahle all/conrrnrction permits(i.e U1C,COnrur.State.Yarlanca eta) FROM TO DIAarE!co
THlCIWESS ntATERLfL
3.Well Use(checltwell use): ft '"'
Water Supply WeU: R' ft• in.
Agricultural 17.SCRF.L'1V
OMunicipal/Pttblic coons To D1An1ETER SLOTStZE
Gcathettnal(Hrnting/Cp011no f` R !u TH[CtQ�ESS MATERIAL Supply) eqtResidential Water Supply-(single)!industrial/Commercial []!Residential WatcrSuppiy(sharcd) It, ft
irrigation III.GROUT
SPlon-Water Supply Well: r•Roni TO MATERLtL
h,lonitcring 0 It. 20 En1PLACEttrEt\T tILT$OD&Ah10UNIT
Injection Well: ORecovery bentonite poured
ft ft.
_ 'AgniferRecharge [�IGroundwaterRemediation f
ft, t
Aquifer Storage and Recovery OlSalinity Barrier
19.SAND/GRAVFy PACK if a Aquifer Test FRODi licableTO M1fwTERiAL
IStOrmwater Drainage ft. E 1rFI ACF.RtENT AtFTtiOD
Experimental Technology et•
Geothermal(Closed Loop) �_I�bsidence Control
ft. ft.
Gcothermal(Ileating(Coolin Return QiTtacer
g ) ' Other(explain under n21 Remarks) FR�t D INC LOG(attach daitional sheets if ne )
TO DESCRIPTIOti cote,haniams aeiVrorl:I C?cola sac etc l
4.Date Wells)Completed; �2`�-2 n/a o ft. S-R'
Well us—, I r
Sa.Well Location: sft. 'Z v ft. Ivb�.I Mac��
2 V Tr. ft.
—,=_;1_C1/e S1140rj n/a
Facthry/WncrNamc ft•
cili it.
6 f 3 Faty iDr{iFapplicable) ft, ft.
! { W
Physical Address,Cl ft. ft
t} and Zip
ft. ft.
Y Zl.tZ1rNcARICS v
County -
Parcel Identification yo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Weil Plaid,one Iatfioug.is sufficient)
22.Certification:
C V• 7S fin/
6.Is(are)file svoU s X Permanent or t 4 C< 2 - '�4.Z
() []T emporary Signature ofCcrtt011 Wcil Contractor
GG Dat,
7.IS this a repair to as existing well: Dyes
(L�-)t_ BJ,signing this fonn,1 harebp cert(�that the u�ll(sj was(were)constnrcred in accordance
jUris Lr a repair,fi11 ont�71e1ti71'veil constnicttan nfonnottar and mp/afn ilia nature ofJhe c PJ'of l is rrc Ord hasOb Liz pru10D or t-ded�o C 01C i o2�0 Well Conrintctiar Standards and that a
repair under R21 rnnrarks section Oren the back of1hisjonn. tile
S.For Oeoprobe/tJPT or Closed-I, 23•Site diagram or additional well details:
construction,only 1 CR I is needed. Indicate TOTAL ells having the same Constriction details use the . You may also attach additional pages if necck of this page to provide additional well essary.
drilled: or well
drilled: ' NUMBER of�vells
9.Total trell depth below land surface: ��j SUB iQTTA.L IINSTRUCTIONS
Fa mnhtple wells list all depths fdLerent(cramp!.-3Q300-and 2@1001 24a. For All 'Wells- Submit this form within 30 days of completion of well
10.Static water level below to of casin • construction to the following:
ljttvter level is above casing,rise 'P g•— G�0 (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
(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 ftinn within 30 days of completion of well
(Le,auger,rotary,cable,direct push,etc.) construction to the following:
FOIL WATER SUPPLY%TILLS ONLi': Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Ibleigh,NC 2769941636
13a.Yield(gpm) Method of test: air pressure 24
c For or.dater Sunaiv +niection Wells: In addition to sending the farm to
13b.Disinfection rype: granular Amount: ��� the addresses) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Foml GUI-I
North Carolina Department of Environmental Quality-Division of water nrso,ueaa
Revised 2-22-2016