GW1-2021-01300_Well Construction - GW1_20210329

For Internal Use Only: -F
?•Well Contractorinformation:
Chris Morgan
Well Contractor Nome 14.WATER ZONES
FROal 70 DESCRU no"
3572 It. n•
\C Well Connector Cettificauan Number R' R.
Morgan Well c Pump, Inc. MOOTER MG far n „cute DR Ln,;uR r Itemlo)OR TO DL1aIETER
Cumealiy Nam fr
e +1 ft. Ta1C1P1F5s MATERIAL
. 81/a ia.
16.INNER CASING ORTING(eo m therat c],,d400 We 2,Well'CDnstructinn Permit: IIS
Litt all applicable well ro mntc(iao FRoal TO DIAhIETFR TMCICNE5a n
Permits t.e U1C,Call-, stale,portanm ere) R. I. la. LITERLIL
3.Well Use(check well use):
ft. ft. In.
Water Supply Wall:
MIS
Agriculmtal -Real fa. To [t DrA
D h7W.Geothermal(HemingtCooling supply) EResidential Water Supply
(single)Indusnial/Commercial R.
QlResidential Water Supply(shared) R. la
Imaehon lO.GROUT.
Non-Water Supply Well: FRonI To afarEnLtL. EnteLACE,1E,,taI non is Anlotar
Monitoring Il-�-'11,, 0 R 20 R.
L�pRecovary 6entonile poured
LUectlon V�ell: fa.. rt.
Aquifer Recharge [Groundwater Rate distion R• fL
' Aquifer Storage and Recovery QSalinfly Barrier IS.SAhm1GRAYPy PACK fa nea6lc -
AQDIferTest Fl[DnI 7D MATERIAL
QlSmrmtvater Drainage R, eaavLacEassxr*+erxon
Experimental Technology fa.'
R
GeothermalQlSubsidence Control
(Closed Loop) [:][Tracerfa.
Geothamlal(Heating/COOhag Retam) racr '-a.DRILLWC LOG(attach additloaal sheetslfneees, )
(ettplainunderw2l Remarks) FR(hnI fa. TO DESCIUPno;Y .wen hamiae.aalament =I-aura.Me.)
4.Date Well(s)Completed•• Z- ZC- Well D)K n/a (� 7v 2
— � 1110 n,
Sa.Well Location: Jn i
px n/a ?5 rt• uX�ft.
Fadliry)Ot Namc C•
Facility lDR(ifappliwble) R, 2
It. ..
Ph lest Ad ress,City.and
•{'71-
" 'C��t n!a 21.REMARI(s .
Coumy Pamcl Idemkfiemion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one laulong is sufficient)
22.Certification:
6,Islam)the well(s)OPermaneat or QlTemporary g,bmamro°fccn,fj,d veil Contractor ( 2G
Dale
7.!s this a repair CO an 35•signing rhir foil,,f llembl,mrrd(hat the uaihes)tmr(rase/ronslructed in aerotHm,e
P ¢SlSling well; Dyes or XQNo uill,15A A'CiC 02C.0100 or 15.4 AVAC 02C.0200 Wel!Coutmcti,n Stand°rdr and dial a
lfthu is a repair fill alit hnoam,w:li rnnNntedon infonuatrou and eliplaln the nulure of the C0RT 0flhia rvcordhae bee°prvwded to h,,,ell m00
repair under 21 ratllarkasection or an the burl'ofthisfpmi
3.Site diagram or additional well details:
R.for Geoprobe/M or Closed-Loop Geothermal Wells having the same You May use the bade of this page to provide additional well site details or well
constrmction,only 1 01V-1 is needed. Indicate TOTAL MINDER ofwells construction details. You may also attach additional pages if necessan,.
drilled:
9.Total well depth below land surface: 000
ME riiTTAL INSTRUCTIONS Por nwhiple nails list all dcpdu fd(Qertmt(emmp!¢•3@200'mtd 2�100') Me. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below rap creasing. Division of Water Resources,Information Processing Unit,
ff�vter Jere(is above toeing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
iI.Borehole diameter: 6 (ID.) 14b.For Injection Wells: In addition to sending the form to the address in 242
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push, construction to the followin_:
FOR WATER SUPPLY VVELLS ONLY: Division of Water Resources,Underground Injection Control Program,
7 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7c Method of test. air pressure 24c.For Water Supply E Injection Rlells: In addition to sending the form to
tanular the addres(es) above, also submit one copy of this form within 30 days or
13b.Disinfection t1pe; 9 Amount: 967.1 completion of well construction to the county health department of the county
where consmtcted.
Fonn Gw-1 North Carolina Depamncnt ofEavironmental Quality-Division ofWater Resources -�
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