GW1-2021-06972_Well Construction - GW1_20210505

agstua:1'10N c®1� GW 1
For Internal Use
1•{Veil Contractor information: -
Chris Morgan
Nell Contractor Name 2�1.1i'ATEi2Z0.M1IES q
3572 �, ,em s�, rRoht TO DESCRIPTiorY
y ft. Ft.
NC\Veil Cpnttaeter Certification Number 9 `A
fL it. y
Morgan Well&Pump, Inc. �d�y� X 2�21 ts.OUTERE SINGfrormulti-casedsveils ORLIN...'' ncabte)
IROhf TO DIAIt[ETER
CompaoyN'ante , - ')"i;h[ +1 ft I�CICNEss MATERIAL
6118 in-
2.WelfConstructian Permit#: 16.1NNER sd2t pvc
�� [j U ING ORTT1BtiVG(eatheratai closed-loo
List all appltcohle trellconstnrctiom permits fl.^UlC,Coruat,$rate{arrance,etC) FROM TO DL1atETER
tL THICICNE55 hfATL•R)AL
3.VVcJ!Use(checli:well use): ft. in.
�+vater Supply WcU: ft. in.
Agricultural 27.SCREEN
DMunicipal/Public FROM TO DIAMETER; SLOTS[ZE
QGeothermat(Hcating/Coc)"n SU I rL ft. In. THICIQ�ESs IVIA R1At
g PP Y) �►Residentiai Water Suppty(single)
IindustriaUCommercial QlResidential Water Supply 1 ft' tt' in
frrigation (shared) 10.GROfjT.
Atonadtluter Suppiy Well: Mom To MATERIAL
D(\•IanitDCing 0 � R'
It. EhtPLACEhfENT hit rnOD&AM1fOUKr
bentanite
Injection Well: QlReCovcry poured
n ft.
Aquifer Recharge OlGmUndwater Remediation fr.
Aquifer Storage and Recovery QiSalinity Barrier 19.SAIYD1Gl2AYBL PACK if a iicabic)
Aquifer Test Fit TO M1f L ica
DStonnmaterDrainage EM1frLAcr•.htEr4-r stErtiop
Experimental Technology. ' ft-
�iSubsidence Control fr.Geothermal(Closed Loop) tr.
QlTtacer
000thcmlal(Heating/Cooling Retum) Other(explain under 21 Remarks) rRII LING LOG{attach additional sheets If necessary)
TO DESCR I'ri ti color,haNn
ft. M sOlyrach i a gain size ele.)
�'
6 ft.
.gate Well(s)Completed: 4 Weil 1D#flea � 1
S ell Loc tion: S fr.
3 5 ft.
j'7 n!a jj rr. rt.
Facil' /Otvn am
Facility fD11(ifapplicable) ft. 6e�ft.
t S �G ft. `�1cC{ ft
Itsical Address,City,and Zip 1 � 2-'9(4& ft. ft.
n!a
21.It MARKS
County
Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
one lat/long is sufficient)
22.Certification:
6.Is(are)the woll(s) ).'Permanent or LJ'�---},T LPC /41171 T
_emporary Signature of CeRtfipd Wcll Contractor
7-Is this a repair to an existing w PT signing this fonn.I lrerebj cer drat nine nril(s)twos(u erel constn cred in accordance
Ifthis is a repair,frll art knottier tse!1 constnrction nfonnotiau and mplaire the nature ojtNe c Pl'oI h Isr record has been pr ov tied io the wail ou ner Well Conrlrmctiar Smndordr and that a
repair under 421 renlarl3 section or on die back of thisform.
23.
te
am or additional well details:
S.For Geoprobe/DPT 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells drilled: ' construction details. You may also attach additional pages if necessary.
9.TotnI well depth below land surface: _1�L.(J SL3I _r1AI,B''SUCi IONS
l:ot•rnuklple wells list ail depllrs(/dperenr(eranlple-3@200 and 2@100� (f') 24a• For All Wells- Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of using:
Ijnl2ter level is above casing,use r' (ft.) [Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
(rn,) 245.For Iniectio,n-Well,: In addition to sending the form to the address in 24a
(Le Well construction method, rOf@fS/ above,also submit one copy of this form within 30 days of completion of well
(Le.queer,rotary,cable,direct posh etc.) construction to the following:
FOR WATER SUPPLY MFELLS ONLY: Division of'%Vater Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
I
13a.Yield(Val)) Method of test: air pressure '
24c.For Water Sunpiv&sniection iWells: In addition to sending the form to
13b.Disinfection type: granular DZ the address(es) above, also submit one copy'of this form within 30 days of
Amount: completion of dell construction to the county health department of the county
where constructed.
Fanti G1V•I North Carolina Department ofEri ironmentat Quality-Division or'Voeer Resources
Revised 2-72_2016