GW1-2021-01556_Well Construction - GW1_20210309

1•Well COntractorInfO ForIntemal Use Only:rmation: -_ ._.....�_.. ....
Chris Morgan
1'reli Contractor Name
14:1irATF,R2pg
3572 R 0 RECEIVED rRo To DESCRIPTION
NC Weli Contractor Certification Number SC rt. 1 ft.
Morgan wen& Pump, inc. MAN X 9 2021 n' l rt.
Company IR�IOtt�R CAST IG(for multi-cased mils)QR L
P Y Name TO DIAaIETER INER Rfn lirrbley
In¢.1111 ; �n r ° +, rt. Tr�ctavEss 14ATERIAL
2,-WCII'Construction Per ff s tls ;n.
mit 7; DW R Section lG.iRNER CASING OR TUBING( eothermni c osed-loo Pvc
List all applicable ur!lcorrstrucdarr permits(f.e.UlC,County:State,Narinnce,etc)
FR011t TO
3.Well Use(chech'veli use): DIA51ETER THICKNESS n. ft atATERI,u•
Water Su in.
PP1Y Well: ft. n•
in.
Agricultural �- 17.S CREEN
}-rGeothermal(Heating/Co olin Su 1 DMunicipal/Public rROnt TO DIAMETER
g Supply) DlResidentiai Water Su j 16 SLOT SIZE THmImESS a.LITERIAL
ilndustrial/Commercial ft. in.
PP Y�(singlc)
DlResidential Water Supply ft. ft.
Irrigationpp y{shared) in.
NOR-ihrater Supply Weil: 18.GROUT
FR062 TO MATERIAL
1�lOnjtOl'Ing i—i' 0 ft. EhIPLACERtL•N•r11L•TiiODSA�t011\T
I''u✓ell: DlRecovcry 20 ft. bentonite
ft, poured
'Aquifer Recharge rt.
CIAquifer Storage and Recovery Groundwater Remediation ft• ft.
Aquifer Test oSaliniry Barrier 19.SAiVDIG pACI{(if ann ifcabta PR All ro ntATERiAL Experimental Technology [�iStorm'vater Drainage rai►LACrRIEn-ralrTHOD
Geothermal(Closed Loop) 01Subsidence Control
DITtacer ft' ft.
Gcothetntal(Heating/Cooling turn 20.DRrLLING LOG(attach additional sheets if necessary)
Other(explain under r21 Remarks) FRc I To DESCRIPTtON Dute Well(s)Completed: (color,hardness soiVroch t c eta;n s;�etc.)
4. 2_g Z� ft. ft.
---�_. well IDr Na e
5a.Well Location: S ft• v ft. t�
I CJ t-le_ V ft.
n/a ft. �v o
Facility/OwncrName n-Facility r'G r4 n�
I q7 6 /`i e41.4 b � ft. � 6� ft. 1 �
physical Ad ress>Ciq%and Zip r G-^���T�ar( ft. ft. -
!ift. I ft.
County n/a 21-REi4iARICS
.111ifi, lion No.
Sb-Latitude and longitude in degrees/minutes/seconds or decimal de(p�I
(ifwell field,one lat/long is sufficient) d grees:
22.Certification:
G.Ware)the neii(s)„Permanent or DI_em-r ,,,
pora,Y Signature of Ccnr 0: 1 Nclt C no uactor 6 `-�Z'
7.N this a repair to anexistingknown
BI signing this rmt,I Irereb� mrtrn drat t/re uell(s)iros(u:errJ constnrcted in accordance
well: Dives or 1,1
If this is a repair,fell art bnowm'veil constnrction infantradnn and etplain the nature of cafe ojdlis record Gas bee»provide rto die well ounce
repair under�'�/ranrarls section ar at the bark oftlris(ornr, tvr[h hA hrC.dC 0?C,O100 or IS_9 NCAC 03 C.0200 Fell Cons[rnctia+Standards and that a
F•For Geoprobe/DDT or Closed-Lermal 23.Site diagram or additional well details:
construction only 1 G6Lr I I needed•Indicate TOTAL I\'[J1vigER oWells having f wells You may use the back of this page to provide additional well site derails or'veil
drilled: construction details. You may also attach additional pages if necessary.
9.Total'veil depth below land surface: SLB�T'--A RS'STRUC T IONS
For rrrtrltiple[sells list all depdrs jdgere,it C le-3eram ��p @-00'and3@!00') (`'} 24a• For All Li'ells: Submit this form within 30 days of completion of well
10.Static Water level belocv bop of casing:
L/�j construction to the folloning:
ter level is above casing,use"=" (ft)
Division of Water Resources,Information Processing§Jnit,
11.Borehole diameter: 6
,1617 IWait Service Center,Raleigh,(in.) g ,INC t 2-
G99-lGi7
12.Well construction method: rOfBry 24b.For injection b.Veils: In addition to sending the form to the address in 24a
(..a.auger,rota above,also submit one copy of this form within 30 days of completion of%veil
rotary,cable,direct push,e[c.) construction to the following:
FOR°�'ATL2 S�'p!-1'�'TI.LS OPz qr; Division of Water Resources Undergro
und wound Injection Control Program,
I3a.Field(spat) Y 1636 iVlaiI Service'-enter,l2aleiah -
'Method of test: air pressure b .NC 27699-1636
24c for Water SuDDiv�Injection Wells. In addition to sendio,the form to
13b.Disinfection ape; granular �7 the address(es) above, also submit one copy of this form within 30 days of
Amount: G-s QZ completion of well construction to the county health department of the county
Porn OW-1 where constructed.
North Carolina Department of Environmental Quality-Division or Water Resour•cs
Revised 2-22-2016