GW1-2021-02042_Well Construction - GW1_20210620

VV L1�1L uLINSTRUCTION RECORD (G W-l) For internal Use Only:
1.Well ContractorInformatton:
Chris Morgan 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft, ft.
3572 2QZ1
11 ft. ft.
NC Well Contractor Certification Number v U'�t1
�'fpcesSlnkj 15.OUTER CM I AASING(for m DIAAS6TERc11s ORI'H3�f4&Ilcabla)
Morgan Well & Pump, Inc. 3�'p c pi;pn
Company Name +t ft. R. 6 t18 1° sd2l pvc
16.INNER CASING OR TURNG( eothermal closed-loop)
2.Well-Construed an Permit#: ( ' (,�J FROM I To I DIAMETER I THICKNESS I 1ULTERLAL
List all oppllcahle itell constntction permits(i.a UIC.Caum(•.State,l'ariance.etc.) fL ft. in.
3,Well Use(check well use): ft. ft.
�7✓ater Supply Well: 17.SCREEN
FROM I TO I DlAMETER I SLOTSIZE I THICIM'ESS htATER1AL
Agricultural DMunicipal/Public FL ft. In.
Geothermal(11cating/Cooling Supply) �kResidential Water Supply(single) ft. ft. in.
{industrial/Commercial DResidential Water Supply(shared) 18.GROUT.
lrigat'ton FROM I TO IIATERUL rrIPLACEMENTA1LTtiOD&Aotourrr
1L'ona Eater Supplv Well: o ft- 1 20 R• hentonite poured
Monitoring 011ccovery ft. ft.
Injection Well: —
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicabW
DAquifer Storage and Recovery QlSalinity Barrier FROM I To I MATERIAL. FniPLACEM NT aIFTHOD
Aq°iferTest DStormwaterDminage ft. ft.
Experimental Technology �ISubsidence Control ft. it.
Geothermal(Closed Loop) OITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRnMON(color,hardacss.soll/ratk l c•ormlo situ etc l
Gcothemtal(Heatin�Cooling Retum) Other(explain under>:21 Remarks) ft. ft,
4.Date Well(s)Completed:(a well ID:;n/a
Sa.WellJet
cation*
)1- � ;e baltpa
Faci{iry/Oxvncr iVamc ,^, Facility iD�(ifapplip ft. ft.
//
ble) _
Physical Address,City.and Zip 21.REMARKS
County Parcel ldendficationNo-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ife'cll frcld,o lq cicnt) 22.Certification:
�A_S� I /I/
Signature ofCettif)6d.well Contractor Date
3:6.Is(are)tile well(s) Permancut or OTemporary G'
By signing this form,1 hereby certi'that file wells)Was(were)constricted in accordance
7.Is this a repair to an eaestirig well: Q4Ycs or No rvilh 15A NCdC 01C.0100 or 151 NCAC 02C_030D[Nell Constn,ction Slandords and that a
If this is a repair,fill out 6nawa well constntction information and explain the nature of the copy of this record has been pmvidPll to the well ou ne:.
repair under 1421 remarks section or on the back ofthisform• 23.Site diagram or additional well details:
S.For Geoprobe/D€'T 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 necessar)'.
drilled: ' IL s—uBMITTA_.ENS t FtUCT IONS
9.Total`yell depth below land surface: Z� (f`L) 24a. For Ali Nyells: Submit this farm within 30 days of completion of well
f--ot•multiple walls list all depths(''dLerenr(example-3 a 200'and_2 /1001 construction to the following:
10.Static water level below top of casing: Iy (ft.) Division of Water Resources,Information Processing Unit,
If Crater level is above casing,use"r" 1617 tVlail Service Center,Raleigh,NC 27699-1-617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the followinc:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL�INTMLS ONUY: 1636 Mail Service Center,_%1 Icigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuDDiv&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
i3b.Disinfection type: granular Amount G completion of well construction to the county health department of the county
where constructed.
FDntt Gt`r-1 North Carolina Department oFEnvirotvnenta!Quality-Division of.Varer Resources
Revised 2-2-1-2016