GW1-2021-01315_Well Construction - GW1_20210329

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I.Well Contractor informntion: FOr Internal Use Only: ' '" "•
- _. . ..
Chi-is Morgan
Well Cunlmctar Nome 14.WATERZONES
3572 /FRONT To DFaLTnPrION
1 R R.
NC Nell ContmetorCettificodon Narnbet
2 R.
Morgan Well& Pump, Inc. 15.ODTER CASING for molti-euFed naat Company Nante FRONT T DLtatE7ER ORLMER fa Ileablc)
{/J I �.�p--� +T A. fL TFDC(4vEss If R1nL
2.Well Construction P G('`wv� 0`"Z / a liB t0' stl27
1I all ermit#; I 16.INNER CASIN love
npP(lcahle urel/ronrtnrcdonpennftr(i.a UlC Comgl'•Smle.i'arinnc FROM TO ORTURING no at at closed-loo
4 elc) DIAN1kT•ER TRICICNESS
3.Well Use(checltweil use): f4 R. 11. aLveRLu,
Water SuPPIy Well: rf R• fa
Agticulnnal _ 77.SCREEN
Geothermal(HcatinglCooling Supply) �R unieipaVPublic FRONT TO DIANIETER
cam, fL 9LOTSIZE TRICIN'E55 M1LITERInL- Industrial/Commercial &l widen, I Water Supply R• Im
PP y(single)
QlResidential Water Supply ft. ft. tv.Irtiaation pP Y(shared)
Non•Wuter Supple Well: 10.GROUT
FRONT TO NTATERLtL
h4Dnitoring D D D. ENI'"Ce"on"NIMIOD&ANIOUNT
?njaction We1L• QlRccovcry zo R, bentonae
poured
Aquifer.Recharge 1-�, fL R.
Aquifer Storageand DGmundwater Remediation ft. R.
Recovery Salini B 19.SAND/G Rquifzr Tes[ � [Y amer RAtrEt.PACK iia Ilwblc)-
�]IStom)WaterDminage FRONT rt TO NGL Experimental Technology ft. TATERIAL F.NIPLdCENIENT METHOD
PCielithermal(Closed Coup) 0IS7lbsidenee Control
QlTmcer rt' [t.
Ceothomlal(tdeating(Cooling Return '-0.DRILLING LOG(atmch addlnanm shsasT)
Other(explain under 21 Remarks) HiO11 To eets lrneres
4.Date Wells)Completed• _ _ G °ESCRIPTION anion nardaes;s -.Cl:h In slu,OW
Q ft R.
Well IIY,?n/a -r
So.Well Location: --- S ft. i0
o f nla R.d rL O S
Facility/Otvncr Npmc R.
Fenn, rD:(iroppli dble) fL ft.
f /
J/�l M C Sir 1Tf /
Fly I dd11 Cn) and7rp I'c.r i`7 1•'tJ (/ 7w/,�.1..._ rr. fL
County 21.REMARILS
Sib.Lnlitude and longitude Fa¢el[dcnufieotionN '— '
t.
g IDdegrees/minutes/seconds or decimal degrees:
(ifwdl ficld,am jut/long is su6icicnq 1:. .:., -
����•[
!----C'��s N —O 1• 'Ops�v 22.Certification:
W 1'
G.Is(arc)the w•ell(s) x'Permanent or OTamintrary o
5i6mnWrc fCcrtifG'd Ncll Conaaclar � 2
7.Is this n repair to an exisdag Dye
s or X iVo B1's'going dnr form,1 hereb Daley—'
fflbisiearvpair,fi/famknorwnva,0.IN tCrion infanuarfon ar�splaia life nature afrim mpl oflGirrecard0as bean pn15A NCrC 02C-0200 teas u
reill,15A A'CAC 02C.0/00 ar ISA NCAC @C.0200)Nc•1f CanelnrcnnSmedin uod...
rrpai,under:?!renurrls seclian Oran!bc bI a iltts jarnr.
G.For Geoprobe/DPT or Closed-L 23-Site diagram or additional well details:
constrction,Dnly I GW JI is needed. Ind me TOTAL NUMB R owells having fwellsme You may use the back of this page to provide additional well site details or Well
drilled: consimclion details. You may also anach additional es a 'pages)fnecessary.
9.Total well depth below land surface: QU SUBtYrIT AL INSTRUCTIONS
For nuddp/e nyl/sfisr all deptiv/fdfp¢renr(emmpfe-3@300'and2@100� UI 24a. For All Wells: Submit this form within 30 days of completion of Well
10.Static water level below to �D conswetion to the Following;
jnmer fore(jr,abovecnsing,use •P Of Casing:
(ft.) Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,PIC
27699-1617
rota 246.For injection_ el�sc In addition to sending the form to the address in 240
t2.Well construction method: rotary - above, also submit one copy of this form within 30 days(i.c.auger,rotary,cable,direct push,etc) of completion of well
conswetion to the Followina:
FOR WATER SUPPLY A CLLS ONLY: Division of Water Resources,Underground Injection Control Program,13a,yield(,pat) _ 1636 Mai]Service Center,Raleigh,NC 27699-1636
Method of test. air pressure 24e For iirarer$➢poly E Infection Wells: in addition to sending the Calm to
13b.Disinfection type: granular the address(es) above, also submit one copy of this n to sending
30 days of
Amount: completion of well copy to the county health department of the county
where Wilsweted.
Form GtV.7
North Carolina Depamncat ofEnvimeracntnl Quality-Dwision of water Resou an
Revised 2-22-207fi