GW1-2021-06943_Well Construction - GW1_20210505

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For Internal Use Only.
L Well Contractorinformation:
Chris Morgan
Well Contractor Name 14.WATER ZOPffiS
FTt011 TO DESCRiPT10iS
3572 ft. ft.
NC Weil Conuaetor Certifitmtion Number R' M
Morgan Well &PUMp, IriC. te.oU 1>,a cAsaly�troy maltt ease8 svelte pRI tNER ra neaute
FROM TO DIA 1EMR TH erarrSS MATERIAL
Company Name +1 ft. b ft. 6118 in, sd2t
pvc
2,Well'Construction Permit#: `/j�{ 16.INNER CASING ORTUBING(eothermat erased-loo
List n(1 nppllcahle u211 constuction perm,Cahn arTancG etc. FROM TO DIANMER THICIMESS 11,1TERIAI
ft in.
3.Well Use(check well use): fL
ft. la.
STJater Supply Neil: 1TSCREEN
Agricultural DMunicipal/Public rRolt To nrantt TER st orstz� TxtctaeEss 1L1TEtitt►I
oeoihermat(Heating/Cooling Supply) WIResidendal Water Supply{single) fL to
Industrial/Commercial It. ft. in
�,IlResidential Water Supply(shared)
litigation 19.GROUT.
Non-Water Suppty Well! Mom TO ,17ATERLIL EhiPLACEIIENT aIL•T110D Gc A110UnT
0 fL 20 R; bentonae
Monitoring DRecovery poured
Injection V✓elh ft, ft.
Aquifer Recharge [Groundwater Remedialion R' ft.
Aquifer Storage and Recovery QlSalinity Barrier 19.SAND/GRAyFh PACIf if a liable).
Aquifer Test FR01T TO 1IATERTAL
QlStormwater Drainage ft, ft. EBIPLAC£ai£NT II£TROD
Experimental Technology Ell Subsidence Control
Geothermal(Closed Loop) (Tracer ft. ft.
0 20.DRILi ENO LOG(atta(h additional sheets If aecess )
Ccothcrmal(Heating(CoolingReturn} Other(explain under�21 Remarks) FROdt TO DESCRIPTION color,6ardocss,soly— 1 4-rainsbr etr!
ft. r
4.Date)5/ell(s)Completed: ID'
Wen I1D�n/a , 30
In Sa.Well Location:
ft. s5 ft.
n/a SS ft. rt.
Fac�thyl %vnor a amc Facility IDn(ifapplicable) ft. f{• ..
Physical Address,City,and Tip ft. ft.
n/a 21.REMARICS r O
County +'
Parcel Identificatioo-No_(PIN) oCo$5�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S�'.�tt`
(iftvell field,one lat/long is sufficient)
9b A03 22.Certification:
(QL N — O ZI
6.Is(are)the nell(s)OPervanent or DTempomry Stgnatuce of CcntfjJBd Well Contractor D e
By 115ASigning 11tis fo....I hereb��crrt�1h61 the It00)Iva,(were!constructed in accordance
7.Is this a repair to an existing well; QtYcs Or is No wide/3,t AC-4C 01C.0100 or/Sri NC1C 02C.0200 Well Cowintction Slandar*and that a
T1111s is a rapnb;fill art knotty:tveG construction information and explain the nautre of the capi-of this record has been provided to ilia ucit oumer.
repair under 011 renzatitr section or on the back of thisfoml.
13.Site diagram or additional well details:
B.For 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 I GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t
SLBflTTTAL INSTRUCTIONS
9.Total well depth belowland surface: Tn M-) 24a.Far All Wells. Submit this',form within 30 days of completion of well
rornndttple trn/1s list all depths tfdiereni(erample-3@200'and 20a 1001
� construction to the following:
10.Static water level s top of casing:_ 4[J (ft.) (Division of Water Resources,Information Processing Unit,
ljnvter level is abovecasining,use"+" 4
1617 Mail Service Center,Raleigh,I JC 27699-1617
11.Borehole diameter: et CD.) 24b.For injection 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%rithin 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY'NELLS ONLY: Division of bVater Resources,Underground Injection Control Program,
1636 Nail Service Center,Raleigh,NC 27699-1636
13a.Yield(3pm) Method of test: air pressure 24c.For Water Supply E Iniecton Wells: In addition to sending the form to
granular the address(es) above, also submit one copy of this form within 30 days of
i3b.Disinfection pe: granu Amount: �t>Z. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironlacmal Quality-Division oflVater Resources;'
Reviscd 2-2-2016