GW1-2021-06933_Well Construction - GW1_20210505

ZL&L__A1A-;U'M_b_TRUCT10N RECORD(GW-1 For internal Use Only:
I.Well ContractorInformation:
Chris Morgan I 14: V.4TER2OICS
Nklefi Contractor Name 0112 TO I DESCRIPTION
ft.
3579
rL ft.
NC NVell Contractor Certification Number
UTERRMIG(for "P?= 9)
0
Morgan Welt&Pump, Inc. At T=Mro T11112101ESS 112TTFREAL
Ia Pr C063"VO
qq'410n +1 rt. 1 6 1/8 � in. sdr2l
Company Nanic UV 4 V" - I pvc
��C) 6 1 1 16.INNER CASING ORTUBING(Ferithermat closed-loatil ..
Well*Cunstrutdon Permitt FROM I TO I DEAUEETER I THICKNESS I RUL
rL
ft. I � I
List all applicable i rell constniction pgnnj�tx g.a UIC,Coun(r.State,Jlarfiuice,ere) In. 1
3,Well Use(check well use): In. 1
-ft. IL
%160
16.0
FRO
Water Supply Well: 17.SCREEN
M- GM I To I DIAMETER,I SLOTSIZE I T1UC1aTSS I IVIATER
Agricuiturai OMunicipal/Public rt. I m i I%
;)Geothermal(HcatinglCooltng Supply) DResidential Water Supply-(single) ft. ft.
;31ndustrial/Commercial I in.
I
OResidential Water Supply(shared) 18.GROrJT
n- fnigafion FROM I TO MATEMAL T
rhIPLACENtEN-riirruoDc,,�hioutPOU"
�NouOWater Supply Well: 0 ft- 20 It bentorilte poured
Morlitoring ORecovery rL
Injection Wells- ft. ft.
Aquifer Recharge oGrothidWater Remediation
'
1 19.SAND/GRAVEL PACIC(if analicable)
QAquifer Storage and Recovery DSalinity Barrier it FROM I To MATERIAL P"CrNIENII'METHOD
Aquifer Test OStorinwaterDrainage
Experimental Technology OlSubsidence Control
Geothermal(Closed Loop) Elmo= I 2o.DRILLING LOG(nttn additional sheets If necessary)
I FROMI TO (attach
(color.h2rdaci%solUrotlztxlipgminf=ctc.I
Geothermal(Heating(Cooling Return) n- Other(explain under,"21 Remarks)
4.Date Well(s)Completed. n/a
Well Urm
So.Well Location: I/V6rt. I t-*
®�24 a-Es nis I qoft. 12,0o ft.
Facility/Owner Name Facility ID",(if'opplicabit)
VLb t :1,7 co/A-5^ L
Physical A ress.City,and Zip
co 11W'7(A qQ.. F 21.REMARKS
County ?=I Identification No.(P
5b.Latitude and longitude in degrees)ininutestseconds or decimal degrees:
(if well Field,one lot/long is sufficient) 22.Certification:
Signature ofCarti#.Ed Well Contractor ate
6.Is(aro)the wclI(s)0Permanent or OTemporury
8j,signing this Jana.I herabj,certify that 111c tvgil(s),vas(trere)cateanicied in accordance
7.Is this a repair to an existing well: 0yes or 2)Tqo with ISA A'C'4C 01C.0100 or JjJ JVCAC 02C.0200 Well Construction Standards and that a
U'tMs is a repair,fill out knosun well consintafan infannotion anti explain the nature of the copj-of this recordhas been provided to life'veil owner.
repair under#21 raniarksectian or on the bad-of this farm. 23-Site diagram or additional well'details,.
8.For Geoprobe/DFT or Closed-LOCI Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only I G11-1 is needed. Indicate TOTAL NUMBER of wells -BM-TTA — i
drilled: I SlJ 11 -L DISTRUC.1 TONS
9.Total well depth halos,.,land surface: (4c)o 24n.For All Wells Submit this form within 30 days of completion of well
rorninhiple wells list at1depths Ydigarent(evarnple-3@200'and 304 1001 construction to the following:
10.Static water level below top of casing. Division of Water Resoue Fes,Information Processing Unit,
If%cater level is above onshig,use"+'* 1617 Mall Service Center,Raleigh,PLC 27699-1617
11.Borehole diameter: 6 _ In.n.) 24b.For iniection Wells. In additi an to sending the form to the address in 242
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of"Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY iAT,I:LS ONLY: 1636 Twitill Service Center,Raleigh,NC 276994636
air pressure iniz the form to
13a.Yield(a m) Method of test: 24c.For Water Supply Injection Wells:� In addition to sead
.P the address(es) above, also submit one copy of this form within 30 days of
,,,P,, granular completion ant of the county
13b.Disinfection Amount. n of well construction to, e county health department
where constructed.
Font'OW-1 North Carolina Department omaviro nmLntal Quality-Division of"water R=OttfCoS Revised 2-212-2016