GW1-2021-01572_Well Construction - GW1_20210309

1.Weil Contractorinformation: ForTrltemal Use Only.-
Chris Morgan CEIVED
ttrell ContractorNnme 14.14r-4TERZQNES. .
3572 IY1�K "X 2021 [FROM TO DES ON
ft.
�C tY11 Contractor Cett riicadon Number
Morgan VI/elt c pu(pnforrit3tPon Processing Unit �' it•
Company Name pump, inc.l DWR Section 0° m+Q r mu+n cased,vetts OR OAI TO DWl1IETER 1 R(ira ileablo
+t R. ft T9ICKNESS itfATEtilrtL
2•Wetl'Constructian Permit.0 �� 6 va i°_ sdrtt
16.INNER CASING ORTUQiATG(eotberntal closed-too pvc
List all oppllcahle n2ll consrrrictiorr penairs(i,¢(//C Cottnp:State.Yorlance errwJ "Bolt f�
TO DIAAIEPER THICIfNESS 3•Well Use(check well use): ft ;a KATEtttAr,
Water supply Well: ft• ft. in.
Agricultural 17.S CREEN
Municipa!/Pt+blic FROM To -
Geothetmat(Heating/Cooling Supply) IResidentia!Wntet`su it DtAit�R OTSIZE TH1C;t11'ESS M1LITERIAL
Industrial/Commercial In
PP1Y'(singlc) R.
Ini DResidential Water ft.
aatiot) tQ
Mon-Water Su ROUT..
PPIy well: 10.G
rRom TO
Monitoring O it. 11AT EMPLACEntElTa1ETFIOD&antOtmT
IrUection Well: []IRecovcry bentonite poured
Aquifer Recharge ft. ftft.
(Aquifer Storage and Recovery OGMundwater Remediation ft. ft
Aqui Fel-Test []ISallnity Ban ier 29.SaND/GRAV>;I,pAgC fa licablc).
�IStormwaterDrainage FROM1T ro t1+ATCRiA
ogy
L
Experimental Technol ft, et. t^*r+.acr•.a+s�vT ntsreoa
Geothermal(Closed Loop) DISubsidence Control
ft. ft.
Ccothcrnlal(Heating/Cooling Return Tracer
30.DRI;,LLP1G LOG(attach additional sheets ff necessar
' . Other explain under 21 Remarks) FROMFROMTo y)
DESCRIPTION Color,hardness,soll/rodc 1 C_tale size etC)
�.Dnre t�/ell(s)Completed: Z Q �jf n/a it' fs. �,
bVe111iD# � ft. 0 /
Sae Well Location: ft. � Yt
1P�
�S �J� 1 �- it !+ ft.
IT�i nla
Facility/OtvncrNamc it
GIB
Facility iDm(ifapplicable) ft.S' q/ �G74f(� ft. it.
P ;kal Address,Cry.and zip + •7 ,+'6 O((t= it
County n/a 21.REMARILS
Patrol Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll Field,ono tat/long is sufficient)
22.Certification:
6.Is(are)the hcIl(s)0perMallent or OT p cm ovary Signatureofccr i ell tiVcllContractor
7.h this a repair to an G Date
p ev,# well: Dyes or n NO Bl+sigtring!!ds faro".I/rerebp crr(h,Nm(the ttrll(sJ+vas(ivereJ corutnrcted in arcm'dnuce
M ai is a repair;fall and 6irotLsr well coastmction information and erplah,the nutarr of the 'rope ofil is record has been prJS-1 AI to the 2C'name".
GdC 0_C s been
or I5.•t NC. 1h 02C.020D i. Cons(nrctlurr Smndards and Mat o
repair Hader„31 renmrks section or oar dre bacF ofdalsforna.
S.P'or Geoprobe/F?_zz F or Closed-, 23.Site diagram or additional well details:
d. l Geothermal Wells having the same YOU may use the back of this page to provide additional well site details or well
drilled:
construction,only 1 GR-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total ivell depth belosy land surface: �;20 SLBK t tAL INSTRITCTiONS
I ar mlrkip/e"'ells list all depths lfdiperear(example-3 r@r 200•and d@100� (�`) 24n.Forte;ells: Submit this form within 30 days of completion Of well
1D.Static water level bolo,.v top of casing: construction to the following:
tI enter level is above casing,use *+., �� (ft:)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
rota 246.Hor fnjection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ry above,also submit one c
(i.e auger,rotary,cable,direct push,etc.) copy of this form within 30 days of completion of well
construction to the following:
FOP.WATER SLII'PETr�4�LLS ON-LIr: Division of Water Resources,Underground injection Control Program,
13a.Yield(gpm)—�L= . air rassure 16361Vail Service Center,Raleigh,NC 276994636
Method of test. P 24c.For Water Sunnis&Infection Neils. In addition to sending the form to
13b.Disinfection type: granular Z-oZ the addresses) above, also submit one copy of this form within 30 days of
Amount: completion of%veil construction to the county health dep ent of the county
where constructed.
Fonn GW-1 North Carolina D epartncnt of Environmental Quality-Division ofWater Resoures
Revised 3-22 30t6