GW1-2021-06944_Well Construction - GW1_20210505

2`131-1-RUCTION RE
For Intemal Use only:
1-Well Contractor)satformation:
Chris Morgan
!hell Contractor Name 14.WATER 20NES
FROM TO DESCRIPTIOrti
3572 n, a.
NC%Yell Contractor Certification Number fL ft.
Morgan Well&Pump, Inc. I.s..OD•rEft CAS rNCe(formntti-casedtivclLs ORLMER ir. itcab10)
FROM TO DtAIIIETER THICICN&SS MATERIAL
Company Name +1 ft. ft.
61/8 in sd21 pvc
21 Well-Construction Permit#: �J 16.INNER CASING OR TUBING( eothermat ciosed•oo
l
Gist n((app!(cable uzliconstnctian penarts(r.e L/1C.Counu:State,parianc4 eta) FROMft. TO DIANIETER THICKNESS
p1ATEt1L'tt,
3.Well Use(Checkwell use): ft In.
Ft.
Water Supply`hlell:
17.SCi2EEN
Agricultural oMunicipal/Public MOM To DIAI•IE7EI2 SLOTSIZE
�)Gcotherrnat(Hentine/Coolln Supply) IL tCTQ�ESS hL1TERtAL
g �IResidendai Water Supply�(single) ft In.
lndustrial/Commercial DResidential Water Supply(shared) f
QI R� rm
Eaigation 18.GROUT.
Non=Water Supply Well: reont To h1TATERtAL EhTetacEntEt,-rnTtTtloD�anrounT
A4onitoring o IL 20 ft. hentonite
[](Recovery poured
Injection well: ft ft.
Aquifer Recharge QlGroundwater Remediation ft.
Aquifer Storage and Recovery QlSalinity Barrier 19-SaND/GRA+VI L PACK if a licable)
Aquifer Test FRONT TO E-RTAL 7ETHOD EM1TPLaCF.M1iET'i M1
[]IStormwaterDlainage ft. ft. M1TAT
Experitnental Technology 01Subsidence Control
Geothermal(Closed Coop) (Tracer ft. ft.
Ceotherntal fHeatir>`F/Cooling Return ❑ �0 DRILLING LOG(attach additional sheets if necessary)
Other(explain under 021 Remarks} TO DESCRIPTIOti cm r,hardness,sontrodt Is r grain si A eta)
O ft. 145 ft.
4.Data Wetl(s)Completed. Well 1Dm n/a
15 ft 3p ft.
5a.Well Location: D
h� ft. 650 ft.
n!a SS rt. JJ ft.
Facility/Owner Name Facility iDr(ifapplica t�ble) 1
c ft, ,
J� .
t Nc 2sa� ft Ft
Physical Address,Ci .and Zip
arl✓J n/a 2I•REMARIGS
County
Parcel[lentificationNo.(PM)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iflvell field,Ion I to is sufficient) Q
OO-IOVO� 22.Certification:
r N /Ff
6.Nara)the woll(S)�fC IPCr inanent or T f 'il
_CmporaFY Signature of CeRif111 Ed Wcll Contractor Date/
7.Is this a repair to an existingwell; L—•�1 Y Bj-signing this foray.1 hereby corn fy Ilia'rite Icell(sJ Ives(were!constn,cled in accordance
ljttis is der i ir,fill out dnos7,rvellconstntction infannarton and e Plain the nuture ojthe c py ojrluswith 1514 r re�card�hasob��,pry ded or 15.1 to wel i oi�m^dell Conslnrctian Standards and that o
repair under�,?i rewards section or on the back ojtbis fornt A
23.Site diagram or additional well details-
8-Far Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: '
SL3l�/LTTA� II+ISTI2UCTIONS
9.TotaI is-all depth below land surface:� �
Fa'm„ltiple[re((s list all depths fdLerenr loran, le•3 > > (`) 24a. For All i3reDs; Submit this form within 30 days of completion of well
p @_oo'a„d_@to0� construction to the following:10.Static crater level below top of casing: S
!jn'ater lore/is above casing,«se••+^ (ft.) Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,PIC 27699-1617
11.Borehole diameter; 6 (in.)
24b.For infection 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY Y ELLS ONLY'! Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,-Raleigh,NC 27699-1636
13a.Yield(;pat) Method of test: air pressure 24c.For Water Sun Iv,&inlection wells-
In addition to Beading the form to
13b.Disinfection granular Amount: the address(es) above, also submit Eone copy of this form within 30 days of
d completion of well construction to ttIhe county health department of the county
where constructed.
Foam G1V-1 Nlorth Carolina Department ofEnviroamentat Quality-Division oFNa[crrtesoures Revised2-32-3016