GW1-2021-01304_Well Construction - GW1_20210329

it, , LON RECORD
For Internal Use Only:— I_ _. •
1,Well Contractor information:
Chris Morgan
Il'ell Commctor Name 14.R'ATERZONES
FROM TO OFSCRm ION
3572 of ft. o rt.
NC Nell Conuactor Cenidcadon Number ft. ft.
Morgan Well &PUrrlp, Inc. Eft CASTING(for multi-msed+vcllsl OR LINER n[
]FRONT nevbte)FAOJI TO DIMIETER TEUC[4YEg5 Company Name +] fL MATERIAL
2.
ff 6118 in. sd27
16.INNER CAS NG ORTURSNG( ta therrial closed-loo List all applicable pvc
!Veil Construction Permit 8
nhle aefl ti canrtrtcttva pe nKr(1.GU/C,Cvus(r.Sra/e,{arrnnce.elc.J FROat TO IT METER THICKNESS a,TERLIL
3•Well Use(check[veil use): rL [1 rt. 1n'
Water Supply ,Von: IL R. In.
77.SCREEN
Agricultural DMunicipaUpublic f1tOA1 TO DI Ix II R SLOTSIZE
Gcorhermgl(Hrntma'Coolm Supply) it. R. if
fC°vim M1G 1
8 PP y) �Residendal Water Supply(single)
Ilndustrial/Commercial Residential Water Supply(Shared) fI ft• m.
Im anon Ia.GROUT
Non-Water Supply Well: rRON 'to a1ATettIAL
C11PL10EMEM NETtmD tk ANOUNn
❑Ih4oniloring D R' ft banlonite
QlRecovcry poured
Injection Weil• n. ft.
'Aquifer Recharge Groundwater Remediation ft. ft.
(Aquifer Storage and Recovery Dsaliniry Barrier 19-SAND/GRAYLLPACIC(ifn Ircable)
AquExperimental
Test FROM i TO MATERIAL
[uStortnwaterDminageft.. F.atPLACF.MEbT NF.TROD
Experimental Technology ft.
QISubsidence Control ft.
Geothermal(Closed Loop) MiTmcer rt.
Gcothcmlat(Aeating/Cdolin Return) '-0•DRILLWG LOG(attachaddinonalsheets6necssary)
g ) Other(explain underr:21 Remarks) �017 TO DESCRIPTION cobmhvlevcss,soiVmrl:lr v=
(Jft. Zf+S ft niviv etc.)
.Dare Well(s)Completed: � ���Z � Well IDS n!a •r i'-
Well2$ d ft. $rd&I r1-Sa.Well Location: 1 [ O ft 9 -V p ft, SQ.t) ^—
.� {�4/ �trt�--f'.... n/a 0 rt. brt.
FaefiLry/Otvncr Nlamc Facility ID",(ifepplimble) Ft.
S6o
-�tkL ab Moat uv 1\� n.
Ply.Miad Address,Cn}.and Zip
�/t r)e •�i6s8 a0 9sy6 '21.REYFARICS
Counry
' Parcel[demification No.(PM) �
Sit.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(ifs:•cll field,one hiblong is surTieient) p
?S 6oYS`/ £�0. 0 8 775� =2.Certification: I
ll
G.Is(are)file wel(s) ): Permancat or QlTemporary Signmvm otCert'126d Nell Commctor
Dale
7.Is this a repair to an existing well: Dyes or J�C I4o �ilhr15.1 A,GICrolC OIDOone.I eby or cattily
Clit"
l4e uell0!{Vrll Cnure)e-m�S and lit
al col 1 atco
lulaal0lha ierser#21'VII reafill rks smvleaorall canlie back
infamtofimi and erpfain toe nunrre oflhe cop)•ofthis l5dNrecordhtu100 providedm these rimer.
repair under R21 remarks tec•Ifvn or vrr the Lack ofdtrt rmm. veil
23.Site diagram or additional well details:
S.c•or Geo construction, only 1 or s n ed-LO ed. In Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
dilled: only 1 GLy-I is needed. Indicate TOT.aI,NUMBER otwel)s
conswetion details. You may also attach additional Wages if necessary.
drilled: '
SUBNE 1 T A.L 2 STRUC T IONS
9.Total wall depth hcloly land surface: SO O
Fornndtiplanxllr list nil depths ffdLerem felluaaf-3r;200'and2Qs/003 (ft) 24a. For All ii'ells: Submit this form within 30 days of completion Of well
!0.Stntic water Im•el bdmr tap of casing: L/G construction t0 the following:
lfnvar-le, I is ObI cnsiag,vse"+" (ft.) Division of Water Resources,Information Processing;unit,
1617 Mail Service Center,Rnlaigh,NC 27699-1617
11.Borehole diameter: G (in.)
246.For iniection Wells-
In addition to sending the form to the address in 24a
12.Well construction method: fOtal;l above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,mlary,cable,direct push,c¢.) construction to the following:
POR WATER SUPPLY WELLS ONT-Y: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,I2ale)gh,i4C 27699-I636
13a.Yield(gpnt)_ Method attest: air pressure 24c.For•,-Pater Suunlr E injection-l), s: In addifion to sending the form to
I3h.Disinfection t}-pe: granular beV the addresses) above, also submit one copy of this form within 30 days of
Amount: completion Of well construction to the county health department of[he eouniv
where constructed. -
FonnO`d%-I North Carolina De artmcnt aFEvrimame P nul Quali+y_Di.ision oFNvamc Rezo..rccz Revised 2-2:_20I6