GW1-2021-00599_Well Construction - GW1_20210205

- �•• AIMIN RECORD GW-
2.Well Contractor information: For Internal Use Only.
Chris Morgan
'an Contractor Name 14.IVATERy0NR5
3572 rR°°1 oFscmPTtov
wo ft• IL
NC Well Conttactm Cenificanan Number
Morgan Well& PUMP Inc. � R.
t1OAI CASING Far maltl-cveed'lob OR Company Name FROG( TO DUM1r�ER LNiaR to Oevbre)
+t R. TFUCIOlEss hrA'fERUL
2,Well'Construction Permit#: U R. s ifa ;n• salt
List all a -00 74 7 16.IIVNER CASING ORTUMG Psc
PPIlca6le ual(conrrmrfionpen I FR0111 TO ( eothetTnal closad_loo I U/C,L'alrrr9.&oft Yannn-.M-) R DWIEI'ER THICKNESS AIATERIAL
3•Wall Use(check well use): ff• ;n.
Water SupP1Y Weg: h' rt• io.
Agricultural Imo, 17.S CREEN
Geothermal(Heats LYMumcipaVPublie hi TO DW1IE ea -
g/Cooling supply) rt sL s12n Txrctm-Ess hIA7ER
PP Y) �lResidential Water supply R. 1p'Industrial/Commercial PPY(single)
]IResidential Water Su 1 R. M n- eiton Supply(shared) I&GROUT
Non-Water SuPP1Y Well: FROM To
Monitoring o rt R. atATER1AL EhiPL\CFbtEM h1ETHOD@Ah10Utir
Injection Well: Recovery Oenuonae poured
Aquifer Recharge fL R.
Aquifer Storage and Recovery fD-1�Groundwater Remediation ft. ft.
Aquifer Test LPSalinity Barrier 19-8d1VD/GRAVEL PACK I irapelicat,
QlSmrmwater Dminage FRohr TO nrATEarwL
ExperitnentalTechnology ft. ft. taxPt-\ irart•hiErxoo
Geothermal(Closed Loop) DSubsidence Control
R. R.
Geothcmlat(Heating/Coolin Return QlTracer
20.DRII.I,ING LOG(attach a_scm al shcels H neeeat
A J)I Other(explain under 21Remarks) FROM To )
4.Date WEII(s)Completed: -ri - L� DE SC Nreotnr,na.aae<''r°1D`°`xt ="mrtra emel
Well RY,:fl/=_ t<. d .r
59.Well Location: ft.
PO4n �;
"(� 2 M� U R ft.
n/a Faciiiry/Ovmcr Nnmc rt• R.
Foci-
..lDk(ifaligble)
R. R.
Physval Address City and ft.
�t 1 Cr0 p ft. R.
Caumy '*A(* /00 710 2L REMARKS
5b.Latitude and longitude In de reel/ Pmccl Identification CO.(PIN)
Orwell
field,Inc lat/long is suilicient)g mrDutes/seconds or decimal degrees:
�S 5,YS Z1 I N — X 1. 1_7 / C,' 22•Certification:
6.Is(are)the u'oD s OPe W() rmaacnt or QlTempornry �.��
S Lmatum ofCcmfj d lVcll Contractor
7.Is this a repair to an esistin w G Dam
g elk Dyes or ®No B1'sf6ning rb[r faun,!hereby cerlfi•rlmt the wu(!(s/"as(were/cDMnu9ed in accmNatcr
Iflhis iv a repair,f!(l ran knau'n,ccdl rnnslrnerion infarnrotiun and esplain the emote oftbe rarer/•oI biro rnrardA-btmn
arpnirurrder m2f renrarkr.rcc'fion ar conafm t ion JJs 'GICO_C.0100 ar/S.4 NCAC lLiC.0200 fpe!l Cvmlmerim,Smndards end that a
f ,(arnt. Pntvidrl/ru the uefl rater.
0.For Geoprobr(DPT or Closed-Loop 23.Site diagram ot•additional well details:
construction. y P Geothermal TOT [yells having due some You may use the back of this page to provide additional well site details or)veil
otil 1 GW-t i�needed. Indicate TOTAL NUMBER of wells construction details. You may nlso attach additional pages if necessary.
driued: '
9.Total well depth below land surface: �(� SUBIYLITTai INSTRUCT
Por tmddple uY/(s Bar all depdn ffJderem(emmple-3Q200'and 2($/001 INSTRUCTIONS
1V1\S
(fL) 24a. For 'Ul [Veils: Submit this form within 30 days of completion of well
20.Static water meta a o - g: ^ENEDonstruction to the following:
IJnnfer mere!is abate casing,use"+" V (ft.)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter:=_5n) f ttJ X 5 NZI 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method: rOtar)/ T�a�,For IDieetion W n
r SSif1(,)abbEl'r--- In addition to sending the form to the address in 24a
O.e.Roger.mtmy cable,direct peak etc) rIOc@ e,also submit one copy of this fort within 30 days of completion of well
construction to the following:
F
OR[VATER SSUPPLY WELLS ONL'_'y DW Division of Water Resources,Underground Injection Control Program,
Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
}Iethod oftest: air pressure 24r;For;pater So IV E infection Wclis: Tn adtii6on to sending the form to
Disinfection t pet granular --
,L the address(es) above, also submit one copy of this foci within 30 days of
-----� Amount: completion of well construction to the cowry health department whero rnnstructed. eP rtment of the county
Farm GW-I
Nueh Camiina Depaament ofEnwronmenml Quati,,-Divtt,on of Water Resources
Recised 2-22-2016