GW1-2021-01330_Well Construction - GW1_20210329

aI TION RRrnRD Gu/-1
For Interco%Use Only.
i,kyell Contractor Information:
Chris Morgan
Wall Contractor Name 14 IVATER ZONES
FR Al TO DESL'RIPCION
3572 C) it.
R.
NC%veil Contractor Centficadon Ntunber fL f.
Morgan Well &Pump, inc. t9.ODTERCASMr- re,no i-eesedwclls ORLINER lr unmal[R01I TO DIABIE"rER THICKNESS Company Name <I R, '77 nl EMAL
` fL 67/a in. stl27
'21-263? 7 I6.tNNERCASING OR1UQiNG( eotfiermnl dosed-too pvc
2.W¢ll"C°nstructinn Permit$; c..�)
List all applicable well consnnnlors ennits i.e U/ FROM TO DIAMETER THICKNESS P grate,V—.Ce,eIc) fL AIATERfAL
3,iVdl Use(check hell use); ft• in.
fL tauter Supply WeQ: rL le,
17.SCREEN
Agricultural DMDnicipal/Public r•; I To DtAniETER SLOTSIZE
�'Gcarhormel(Haeting/Coollng Supply) r4 ft. I0. TH Ctrn'ESS MATE tAL
PP Y) idendal Water Supply(single)
Industrial/Commercial QlResidenfial Water Supply(shared) It•
hnaation III.GROUT
Non-Water Supply V✓ell: r•ROai TO MATE RLiL
EMPLACEM1fEn7 M1ILTnOD,4 AMOUNT
�N4DnflOring 0 ft• 20 ft, bentanite
QlRecovery poured
Injjeeton Well: tit R
Aquifer Recharge QlGroundwater Relnediation ft• R.
Aquifer Storage and Recovery DSaliniry Barrier 19-SAND/GRAVELPACIC ita licablc
AIILLIfer TWt FRD1r TO M17ATERIAL
StorralvaterDralnage ft. ft EM1tPLACr.M1IEnT M1iF.TR
�I OD
Experimental Technology �ISubsidence Control ft.
Geothermal(Closed Loup) alTmcer it.
Gcothcmial(fleating(Coolin Return ''-0.DRILLING LOG(attach MESCRIaal sheets if ncicssary•)
g ) . Other(explain under,-;21 Remarks) �O1t TO OE$CRII`TIOY(colon M1aNa solVrvrl:l+ e¢nla she ete)
S.Data Well(s)Completed: 3✓2�i tl Well ID-n/a
ft.6fL a +�
t). <S rr.
So.//Well Location: n fir''^ b1••�
64/04,/ t! �S ft' .ad fL SLlns�sPo1�
nla a R. re. �
I,F//aciliry/OsvncrNnmc Facility rM(ifappli+abic) tS R. R,
766 un�15 /y0 `
PhysiAl Addmss.Ciryt and Zip '
�•Q 4aQ^ Will o6 6 Zo.L 'o-1.i1ErARKS
Coumv �—
Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees/mimtes/seconds or decimal degrees:(ifwcll field,one lat/laug is sufficient)
35.62$Vy-L Di y���gY 32.Certification:
7
6.Islam)the weR(s) )[ petmancnt or QlTemporarY si�gnamrc otCctti tl vdl Commclor Q✓C� 3 �,~
Dar,
7.Is tliis a repair to an existing well: Dyes
Nia BY signing tills(onn.1 berebp errt�Mai ilia m211(s)hyar(were%connnrcied in accordance
I0'lhic is C repair,fill ran knm n uall c0.,vcIion tnfomm[iou a�r T ain rbe nature oJlhe c PJ'15I NCrecord rC.0100r ,]S..Iri1Ca!e tell 200 Nell Cnngnrcrimr Smndardr and t/rar o
repair under 921 remarks section Cron lite back oflbis(onn.
23-Site diagram or additional well details:
d.For Geoprobe/DPT or Closed-Loop Geothermal Walls baving the some You may use the back of this page to provide additional well site details or well
construction,only I GW TA
iI is needed. Indicate TOL A'UMBER of wells construction details. You may also anaeh additional pages ifnecessaq.
drilled: ' 1
9.Total tril SL-Bt UTTAL DISTRUCTIONSl depth below land surface: b t�
pm ogdliplewells list all deprbs lfALerenr(ecnmple-3[LJ200'mrd (f`) 24D. For All Wells: Submit this tans within 30 days of completion of well
?D.Static seater level below tap of using: C/G construction to the following:
!(grater/ere%is a6arc rasing,rrsc^r^ (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 2 7 6 9 9-1 617
11.Borehole diameter: G (in.)
24b.For iniection Wells: In addition to sending the form to the address in 24,
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,etc.} construction to the fe lowinE:
FOR 6VATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,INC 27699-1636
130.field(gpm) � b _ i4iethod of test. air pressure 24c,For.rater Sunnh'E iniection-veils: In addition to sending the form to
granular the address(es) above, also submit one copy of this form within 30 days of
fib.Disinfectionhpe: Amount: OQi completion or well construction to the county health department of the county
,vhere constructed.
Fonn D::'-1 Noah Carolina Department ofEm•iroru IC,,l Quan,y-Dlwt:,o„onvo.cr Rcsou¢cs
Revised 2-L'-2016