GW1-2021-06916_Well Construction - GW1_20210505

M>LJ1l,tt:UiYS'1CRUCTI ON REC®wn e-- y -a .......
For Internal Use Only
i•Well Contractorh formation:
Chris Morgan
well contractor Name 14.W-47211$O.NES
3572
FROM TO DESCRIPT101
it ft.
NC Well Contractor Certification Number R ft.
Morgan Well d:PUMp, Inc, 15.OUTER CASING(for multi-cased mlls)OR LnVER(trn IFcabie)
IRO'( TO D[A'IETER THICKNESS 1fATERIAL
Company Name l c +1 ft' ft. 61/8 in.
3 1 J� sdt21 pvc
2.tTVell'Constructian Permit n; 16.INNER CAS 'G ORTi1BING(enthermal closed-loo
List all applicable hell consrnrctlmr pelouls(i.e.UIC,Contul:Stale,l'arinnce.etc.) FRO'i R. TO it DIAatETER THICKNESS
'tATLRIAL
in.
3.Well Use(checliwell use):
ft.
°lJater Supply Well: 17.SCREEN
Agricultural oMunicipal/Public FROn1 TO DIA'IETER SLOTSt7E THrc[rnEss 'rtTeRrAr
PC7egnccrmat(fieating/CoolinSupply) ft fi. in
g �IResidential Water Supply'(single)
Industrial/Commercial DResidential Water Supply(shared) ft' ft. in
Irrigation I0.GROUT
IL'on-{plater Supply Well: FROM To 'IATERIAL "ENIZ NIT DIETHOD S Ali 10UNT
Monitoring I-r ° tt 2D ft bentonite poured
Injection cA'eIL QlRecovcry ft.
ft.
Aquifer Recharge QlGroundwater Remediation fr• fr.
(Aquifer Storage and Recovery Q FRO'i TO
Barrier 29•SAt�/G O L PACIC(ifa livable)
Aquifer Test 'MATERIAL -IPLACF1fE AT'1FTHOD
QlStormwaterDrainage fr. ft.
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) OlTracer
30.DRILLING LOG(attach additional sheets if necess )
Geothemtat(Heating/CoOling Return) Other(explain under 21 Remarks) O�I TO DESCR[PT[Oti(cola,hardness soil/met;i
O ft. I6 ft.
s c atria size clef
4.DateWell(s)Completed �� I sell 1 n/a
Sa.Well Location: bra-oh Awir.
A ft. C_-
17Ix_ Y�OV1 _ (�VIQy1 We 55 ft. $s ft. JaW
Faciliry/Owner gamc Facility IM"(ifopplicable)
230 1'e l� ft
1 2$6?� ft. ft.
Physic I Address,City.an Zip
ft. ft.
21.Rt.i�iet_RItS
County _
Parcel Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t�HA J ZQ21
(if Well field,one lat/long is suffIcient)
39S, '7367, n —4 @3,t Z2.Certification: ii i C, s
6.Is(are)the aop(S) Permanent or QI=emporary Signature ofCcrttG Ad Nc(1 Contractor D. Z�
7.IS this a repair to an existing well: v , By signing this(Drat,1 hereby curt that the wall(s)was(were)constructed in accordance
fille Dyes OC �I'}p nvillr 1511 MC.dC 07C.0100 or 15A NCAC�MC.0200(Yell Constnrcrion Standards and that o
repair to a under
121 ren out knotyu wall constrrclion in(bnnation and eiplaln the nature ofthe copy oedtis rrcordIron been provided to the ive/i nt+aer.
repair under"2l terra 6s section or on the back ojtais•(oMI.
23.Site diagram or additional well details:
S.For Geoprobe/IDI'T or Closed-hoop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 Mr-1 is needed. Indicate TOTAL NIU-I IBER of wells
drilled- ' construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: Z90 SUI3MIT1 AL RNSTRUCT IONS
pornrnitiple urlls list all depths ledo-erent(erantpde-3 a 300'and I@I00') (t`) 24a. For All �i'ells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:
�O construction to the following:
retrater level is above casing,use •+ (ft.) Ditdsion of Vi ater Resources,Information Processing Unit,
1617 Mail Service Center,-Raleigh,NC 27699-1617
I1.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 farm within 30 days Of completion of well
Ox.auger,rotary,cable,direct push,eta) construction to the following:
FOR WATER SUPPLY NN'RLLS ONL.': Division of Water Resources,Underground Injection Control Program,
1636 Mull Service Center,Raleigh,
NC 27699-1636
13a.field(gpnt) to ?,Method of test: air pressure 24G For.crater Suoniv 8-,Infection-Wells: In addition to sending the form to
13b.Disinfection ty granular the address(es) above, also submit!one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
onn OW-1 Noah Carolina Department of Environmental Quality-Division of Rrater Rcsoures
Revised 2-22-2016
i