GW1-2021-06917_Well Construction - GW1_20210505

_ ... 5-_- J U]N REC®RD �1
For Internal Use Only v
• Welt Cont'ractOrfnformation:
Chris Morgan
ti'ell Contractor Name 14.�i'ATER ZONES.
3572 M. 'NJ TO DFSCR1PTI
NC 1Vet1 Contractor Certification Number
R. R• t
Morgan Welt&Pump
Inc. LB..OtJTEK CASING fror mtdfi_Cased'wCI1S Ol{
rxont TU LnvER ttr. ncabla)
Company Nan1e DL1IttETER THICIGUSS 1fATERIAL
2,WelfCunstructian Permit#: 1`G 67 tG.INNER sd2t pvc
CASING ORTt1BCiV6(antherural rinsed-lao
List all app/lcalde vie/l canstntctfan permits(ie UlC,Cotnut.Stare,{'artmtcr~ercf rROa1 f4 TO DL16[ETER
Txrcrcrrrss AWE UAL
3.Well Use(checic ell use): ft' in'
WI. ater Supply Well: €t' Er 1D.
Agricultural 17.SCREEN
OMunicipaUPublic rttOM TO DLUIETER SLOTSt2E TRICIQ�ESS NIATERrnL
QGeathormat(Hcating/Cooling supply) �l$esjdential Water Su ! 'sin le m ft. in.
0' Industrial/Commercial pp y( g ) rt.
[�IResidential Water Supply(shared) tt. to
irrigation 30.GROUT.
Non-Water Supply Well: rnOm TD a1ATEltL1t
0 ft Eh3PLACENLENTNIETrIOD&AhrOUN7
[]tll4onitAring rr----rt'' � D' bentonae '
Injection LVell: t�Recovcry pourer!
fG ft.
Aquifer Recharge oGroundwater Remediation ft.
ft
Aquifer Storage and Recovery QlSaltnity Barrier 19 S /GRr1 VEL PACK B. if a licabic Aquifer Test FRONT
DStormwater Drainage ft ENtPLaCrNTEhT AtETHOA
Experimental Technology TO fr. MATERIAL
olSubsidence Control
Geothermal(Closed hoop) ft
ft.
O1Tracer 20.DRIT—LllvG LOG(attach additional sheets....f necessary)
00c0themial(Heating/Cooling Return) Other(explain under'r2l Remarks) FROM11 TO DESCRi ON color,hardnM'son/roct:ty c•.in stm etr)
Et.
Unto Well(s)Completed '-2 O-Z li nl Q ft. er
Well Mft8 ft, ft.
5a.Well Location- /V i✓,, 0"t-
Q ft. ft.
C e y4,o* — cc) e c n/a 6 o ft.
Facility/Owner Namc .57yp ft.
fh Facility
(DGr�(liif+atpJpl8iSagb l)��ol . EMfAt.tttcs fFa,/ a
Physical Address,Ctq and Zip O ft. %
t ft.
County -
Pa=l Identification Teo.(PM
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `'y
(if-11 field,one lotAong is sufficient)
�
1>• S1 �0 p) "'QD. _] $ 'Z7s 22.Certification:
6.1s(are)the well(s)OPet n)anent or oTemporary Stgnaturc ofCcrtrfjl d 1Vc11 Contractor ir"t q0 wa
�• Datc
fi.Is this a repair to an existing well; D. Yes or r2)xo Bhp signing Ibis font46 ,I herebh>certJ51 Ilia,ilia Trall(v was(were)coistnicted in accordance
Olds&a repair,fill aut Imam,well constntrwan n/bMiarian antl etplaia the nanrre ojtbe With With'JS,4NCcord bas0b 0 n or pr ad NC Cc uC 1 .?t)o ,Well Consmtctiam Standards and that a
repair mttder m?l rentarla suction or an Ilia back of flits joml.
S.For Geo r pT 23.Site diagram or additional well details:
p obe/D_ or Cloyed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 i$needed. Indicate TOTAL NUMBER of wells drilled: ' t construction details. You may also attach additional pages if necessary.
9.Total ivell depth below land surface: SLBMUTTIk-I'1141STRUCT IONS
fornttrlrtple Walls list all deprbsTfd eretu(erant 1e-J (`') 2aa. For All 6i'ells• Submit this form within 30 days of completion of w
P @_00 and_@lUU� ------• p well
10.Static water level below top of casing: construction to the following:
ff nuter level is above casing,rose"t" LO U (ft.)
Division of Water Resources,information Processing iJnit,
11.Borehole diameter: 6 1617 Men Service Center,Raleigh,NC 27699-1617
(in.) 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 within 30 days of completion of well
(Le.auger,rotary,cable,direct push,ate.) construction to the following:
FOR WATER S PPLY%T,.LLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) G Method of test: air pressure
lac.For Water SuDDiv�infection Wells: In addition to sending the form to
13b.Disinfection w,�pe: granular the addresses) above, also submit one copy of this form within 30 days of
Amount: LAI completion of well construction to the county health department of the county
where constructed.
Fonn OW-1 North Carolina De
partment of Environmental Quality-DI isinn of Water ttesoumcs �
Revised .,...=016
I