GW1-2021-06928_Well Construction - GW1_20210505

For Thtemal Use Only:
1,Well Contractor hfformatten:
Chris Morgan
I
Ulell Contractor Name TO DESCRIPTION
3572
ft ft.
NC Well Contractor Certification Number
OUTER CASING t=ft OR MIRR flrapfFbIL
r T VD THICM JX.'PLIAL
Morgan Well&Pump, inc.
act= ol'if TO gss
ICompany Name +1 in• sdr21 pvc
16.INNER CASING OR TUBING(geothermal closed-lotial
2.Well'Construction Permit#: 9H Wz-[-,C)0(34t3 FROM I To DIAMETER THICKNESS I INIATEML
List all applicable null construction perrairs(i.r_UIC,Canatl-.Slate.11ationceela) ft. ft, In.
3,Well Use(checkwell use): ft. ft. In.
1-water supply Well- MG 17.SrRREN
M TO DIAMETER SLOTSIZE THICIMM M1LITER
Agricultural DMunicipaVPublic; ft. ft, In.
:J(3i.,h.t(Henting/Cooling Supply) lResidenfiall Water Supply-(single) ft, in.
Oindustrial/Commeretal �_ Residential Water Supply(shared)
IR 18,GROUT.
Irrigation FROM I TO I MATERUL I VVIPLACIMM.NTMETUOD C.AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
[DIN'lanitaring DRecovery IL ft.
ft.
WAquifer Recharge OGroundwater Remediation
19.OMANDJUR TOAVE L PACIC(Sif )
Aquifer Storage and Recovery DSaliniry Barrier FR MAapplicable TERIAL I FINIPLACENIEtIrr METHOD
no"
Aquifer Test OStorrawater Drainage ft. It.
Experimental Technology E]lSubsidertce Control ft. It-
Geothermal(Closed Loop) OlTracer 20.DRMLING LOG(attach additional sheets If necessarv)
FROM I TO DESCRIMON(color.hardness son k%'PP.9=10 S17A Cie.]
Ocothcmial(Heating/Cooling Return) M- Other(explain under 021 Remarks) 1 1 .so —
G ft, zo ". I tic
4.Date Well(s)Completed: - L-7_\ 1Aellro-nia
&
So.Well Location- o Kmk—
&I g V ft'$� nis
Facility/Owner Name Facility IM(if applicable)
OCC41c " 40� 17) e-Q; ko ft. TL
Physical Address,City.and Zip ft.
/;12 CPQ J105 :6 T13 421.REMARKS
cdh-nty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if"Vell field,one lotilong is sufficient) 22.Certification-.
A,
signature of Ccrti�ffd Wall Contractor Date
6.Is(arc)the wclI(s)0Permanent or OTempornr.v 157
gjt signing this forin,I heraby rerf�that the wells)was(mere)constructed in accordance
7.Is this a repair to an exIsting well; D—yes or E)Iio ivith 15A AVC 01C.0100 or 15A AFCAC 02C.0200 Well Construction Standards and flint a
if this is a repair,fill out known well construction information and explain the nature of the cap,,of this rucardhas been provided to ilia 1-1i if­
repair under j21 rentarh section or off the back of dUsforni. 23.Site diagram or additional well?detnflsz
S.For Geoprobe/DPTI or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary-
drilled: I I �go S1313MIJITTAL DISTRUCTIONS
9.Total well depth below land surface: _(f L) 24a.For All Wells Subunit this form within 30 days of completion of well
rorandliplawells list all depths Y'dVerent(kromtdc-3@200'and 7051001 construction to the following:
10.Static water level below top of casing. (N Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+ 1617 Mall Service Center,Raleigh,DIC 27699-1617
I I.Borehole diameter- 6 24b.For inleetion'Wells In addition to sending the form to the address in 24a
12.Well construction method; rotary above,also submit one copy of this form within 30 days of completion of well construction to the following:
(i.e.auger,rotary,cable,direct push,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY`hTZLLS ONUY, 1636 IVITall Service Center,Raleigh,NC 276994636
I . air pressure In addition to sending the farm to
13a.Yield(gpm) fz� Method of test. 24c.For Water Sungly&iniectiort Wells:
the address(es) above, also subrnit�one copy of this form, withi 30 days of
in
on to the county health department of the county
13b.Disinfection granular Amount completion of well construction
where constructed.
-Diviston orxVater1zesou=" %evised 2-22-2016
Fong OW-1 .4orth Carolina Department of Environmental Quality