GW1-2021-04253_Well Construction - GW1_20210419

vvt✓nulu 1"'NUMUCTIION REC IC I . ......,....
For Tntemai Use Only: " " -'--
i•Well Contractor Information:
Chris Morgan
Well Contractor Name 14.1YATEItgpNES
3572
FROM ft. TO DFSCRIPTIOiti
NC Nell Contractor Certification Number R• ft.
Morgan Well& Pump, Inc. IS-OMER CASIt G for multi cased ivelb OR LDt1ER ra ncamo)IROAI TO DWIETER THIC[GYESs Company Nante +t ft• (� I IATERIAL
o ft, 6116 in. sd21
2,Well-Construction Permit#;
16.INNER CASING ORTiTBING(etithermal closed-loo pvc
List all applkabie it-ell constntctioa penaits(i.e UiC,Cotagt:Stale,11artance.etc) FROM fL TO DfAtUETER THtCIUVFSS
ft.
MATERIAL
in,
3.Well Use(checltrveil use):
ft. ft. la.
W a 11 ter Supply Wc!!:
17.SCREEN
Agricultural DMunicipal/Public MUM TO DIAMETER SLOT iZE TH["LA- bL1TERiAL
Geothermal(Heating/Cooling Su I r` M in.
pP Y) �Qtesidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) ft R• rn
Irrigation l0.GROUT.
Non•Vttuter Supply lftleli: GROni To d1ATERLt1 EhiPLACE6TL•h[diETHOD&1MOLnT
Monitoring 0 R' 20 R• bentonite
0RecOvcry poured
Injection Well: fL ft,
Injection
Recharge [�Groundvt�ter Remediation ft.
:)Aquifer Storage and Recovery [][Salinity Barrier FR OIft TO SAND/GRAVEL PACIC(if a licable
Aquifer Test QIStoRnwater Drainage R• ATATERTAL FeltPLaCF.01EAT ItETHOD
6xperitnental Technology ft.
QISubsidence Control !t.
Geothermal(Closed loop) QlTtaczr tt•
Gcrothcrntal(Hearing/Cooling Retain 1 �00 L[NG LUG(attach additional sheets If necessary)
Other(explain under,r21 Remarks) TO DESCRIPTION coto,I„Naess sal0tarl;t a araia stir etc)
4.Date W Completed:3-Z Z Wait il3;f J n/a U f t• v f`'
Will p4
—._. pit•
5a.WN Location: 3 ft• ✓OLa� �:i
3 Eft, -70 ft, t--
al)V R:I/A R 11 n/a 'v ft.
it. �,
Faailiry/Otvncr Name t.
lFacility ID (ifapliabic) {,70 c�S M
_ ,�,
Physical Address,City.and Zip
ft. nli
County
Parcel Identification No"(Pi1V)
51J.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^� t✓(iftyell field,one lat/long is sufficient)
22.Certification:
6.Is(are)the hells X Permanent or []Temporary Signature of Carl tvcll Contractor `
G Dale
7•Is this a repair to an existing Weil: YCS Or X 1$0 BY signing this jann,I hereby curt fp that ilia nrll(s)'tax(here)constructed in accordance
jlhtc is a repair,fit!art 6�rottior ice//consintction information anti-Plain the nature of ilia c m,of this record ryas b eat pro or vider)ia Me ive i onmer�ll Conslntcliun Standards and t/mr a
rupair Under m21 remarks section or on ilia back of tltisfornt.
23.Site diagram or additional well details:
G.For Geoprobe/DF,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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:
9.Totni iveli depth below land surface: 7 00 _111 tT A_L�'ISTRUC,IONS
For multiple malls list all depths fdperent(Qrantple-3@200"and 2 1001 (`') 24a. For All i3'eils: Submit this'form within 30 days of completion of well
D.Static rtnter level below top of casing: construction to the following:
G
Titurer level is abut=a casing,rise +^ (fh) Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
i I.Borehole diameter: 6 fin.)
24b.For Injection Fireits: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this form within 30 days Of completion of well
(Le.auger,rotary,cable,direct push,crc.) construction to the following:
FOR WATER SUPPLY Vill OIVUY. Division of Water Resources,Underground Injection Control Program,
1636 Nall Service Center,Raleigh,NC 27699-?636
13n.Yield(gpm) Method of test. air pressure 24c,For Water SuD Iv&infection Welts: In addition to sending the faint to
13b.Disinfection type: granular D�/ the address(es) above, also submit one copy of this foam within 30 days of
Amount C, completion of well construction to!the county health department of the county
where constructed.
Point 01V-1 North Carolina Department of Environmental Quality-Division of"Vater Resouses
p Revised 2-7.2-2016
I