GW1-2021-06977_Well Construction - GW1_20210505

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I.Well ConhricforYitforniation: A lutemal use Only: •�• V•
Chris Morgan
Nell Contractor Name "� i'1 t1'9TER20NES
3572 t�'' FRoni To a>s[RiPiION
R. R.
NC well Contractor Certification Number ��/� Y X J 202 R ft
Morgan Well&Pump, ine• S OUTER CASING rmalucoseaWells OR
Company Name 'fir%CCU Il J Unit FROM TO LINER ra Rca6to
DWIETER THIC[CNEgS MATER[AL
iilarr �, :: . +1 ft. ft. 61/6 in.
q Dv1'R SEctiD," sdd21 pvc
2.Wcll'Constructian Permit#: � .16.INNER CASING OR TUBING(eot[rermai closed-loo
List au oppiicahle tr>?ll coustnicrion permits.(r.e UIC,Coun(y.Stale.l'arnnc,edrr) FROat ft. TO DIAhtEi 1 R
THICICNESS 11r1TERLri,
3.Well Use(checliwell use): R' in.
ilJater Supply Well: ft' R la
17.SCREEN
Al;ricultttral OMunicipaV%blic FROflf TO DIAfl1ETER SLOTSIZE
Geothermal(Heating/Conlin Supply) ft. ft. to TH[CIQtESS hL1TERtAi
$ pp y) ®!Residential Water Supply-(Single)
lndustriallCommercial QIRes;dential Water Supply{shared) f t ft.
Irrigation 10.GROUT
Non-Water Supply Vdei����Recove�r
r•Ron1 TO fl1aTERLtL
Q R. EhIPLACEa1LtVT METHOD&A6 oumr
Monitoring R; bentanite
Injection Well: poured
ft. ft.
Aquifer Recharge (3
Aquifer Storage and Recovery roun m
dwater Reediation
fr.
EllSalinity Barrier 19 ft SANDlGRAVEL PACtf if a ticable)
Aquifer Test Ql FROM TO Storrnwater Drninage ft, FnirLaCcniEnT A1E'rtloD
Experimental Technology FL h7ATERIAL
0ISubsidence Control Geothermal(Dosed Loop) -
QlTracer 20.DRTI•i it. ft.ING LOG(attach additional sheets if necessary!
Gcochcrnlal(HeatinglCOolin Return .g ) Other(explain ender 21 Remarks) Oflt TO DESCRILT[ON cc or,hardy
r ft setUmN:i 4`rain sires ate
4.Date Well(s)Completed: Well IM.n/a 0 15 f t• l
52.Well Location:
1 S fs• 35 ft.
35 �• Z.cd ft. Ya•h t
Y nla rt. ft.
Facility/Ot r Namc a ft.cility 11)m(ifapplicable) ft. ,
`1 O�CtS S (� IC�n tGr1� w,���? ft. rr
Ph sisal Address,City,and Zip
ft. ft.
n/a 21.REMARt�
County
Panel Identification Vo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Weil field,one Iattlong is sufficient)
3S, 550Z 22.Certification:
N _ OQ /�0.Z) (o �r
6.Is(are)tite well(s)
Pernianent or
[]ITempOrary Signature of Certified WcU t On MCtOr Date
7.IS this a repair to an existingw B}signing this fomt,!hereby certify that the uell(s)itvs(were)constructed in accordance
ell: nfun io n No ivit 1SA NCaC 03C.0100 or 151 NCAC 02C.0200 Well Cor"Inrcriar Standords and dial a
!flits is a r epair,fill alit lrnormt rat i1 constnraion infonrmtion anti erplain the nautra of the roPJ'ofthir trrord has been prireided to the;well owner.
repair under m21 rnnarh section or on nc�boa[oftlr[sfornt.
ram or
onal
S.For Geo robe/D.PT or Closed-Loop Geothermal Welts havingthe same YOU
Stray ns the back ofnthis page to provide additional well site details or well
construction,Only i GWV 1 is needed. Indicate TOTAL NUMBER of wells COn m
drilled: ' construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SLBit2iT1AI'INSTRUCT IONS
!rorrrtulriple wells iisi all.deptits y-doereat(e-rTni ie-3@200-and 2@I00J (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
10.Static luster level belowtop of casing: �5 construction to the following:
!f rater level is abovermsing,rise--+-• (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
14b.For infection Wells: In addition to sending the form to the address in 24a
12.WelI 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 WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 i1118Il Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: air pressure 24c,For Water 5unnic Iniection'Wells: In addition to sending the form to
13b.Disinfection type- granular 8GZ the addresses) above, also submit one copy,of this form within 30 days of
Amount. completion of well construction to rite county health department of the county
where constructed.
Form Gttt] North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
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