GW1-2021-00614_Well Construction - GW1_20210205

RECORD M—A) For Internal Use Only.,
i,Mtell Contractorlt ormation:
Chris Morgan 14:IIr9TER2ONES
%Vull Contractor Name FROM Cc. To DESCRIPTION
3579 k
\iC!Veil Contractor Certification Number
t5.. CASiN4 or mvltl-eased 1vC11S 6R R Fit itcahln
a FROM to D1r1t1fETER THIC[QVFSS DIATGRIAL
Morgan Well&Pump, Inc.
+1 R, tG 61t8 In. sd21 pVe
Company name .16.INNER CASING ORTUBING(eotttermat closed-loo
2.Wetl'Constructian Permi# : r•Rom To DIAMEMIX Ttuctcrtrss nuTrnki.
Gist all applicable evil constriction perrairs(i.c UIC,Quay.State,Variance,eta) fL fl: "in.-
3.Well Use(check-well use): ft. ft, fin.
Water Supply Well: 19.SCREEN
FROM TO DIAMETER SLOTSIZE THICIMM MATERIAL
Agricultural 01dunicipal/Public ft, ft. In.
Geothermal(Heating/Cooling Supply) ( Residential Water Suppiy'(single) it. ft. In.
!industrial/Commercial r��. !Residential Water Supply(shared) ip.GROUT.
tt7laatt0lt t1i0At I TO I 'MATERIAL I CNIPLACEbtENTblt:THOD&AblUtmT
l'lo -Water Supply Mfell: o fit. Za f#. bentonite poured
[Monitoring ORecovery ft. ft.
Injection Well:
ft. ft:
Aquifer Recharge OGroundwater Remediation 19 SANDIGRAVI;1,PACK ifa ticabtc).`"
( iAquifer Storage and Recovery OSallnity Barrier I FRONT TO I MATCRTAL BMC SMENT\ETt30D
Aquifer Test OStormwaterDramage I
Experimental Technology DSubsidence Control fL ft.
Geothermal(Closed Loop) DTracer 1 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under ,21 Remarks) M01V To I DFSMIMOY color,hon acss.solUroch 0,11c,etala sbta,ctmi
it. ft. i ,
4.Date Well(s)Completed: _ Well 1D#n1a D'•S- I!' I 4 e' D' f A bf-ri
Sa.Welt Location: ,g.
YLh� �r mo Y1 nix rr. rCi1t•�,�
Facility/Dtvnor Name Facility IM(ifapplicable) R'
ZW 'i ru l `�t'uY'e' �Y'r `r t S�littt/� ✓� Z {t{ ft. fL
Physic j ddress,City.and Zip
ft. ft.
1`+Otih�titit`� nla 21.121;1YARICS
County Parcel Id cad f ication N o.(PIN)
5b.Latitude and longitude In degrees/miautes/seconds or decimal degrees:
(fftvell field,one Iot/long is sufficient) • 23.Certification:
ti i J,zc—t !t',�)
6.1s(are)the wou(s)n ermo neat or [�Temporary Signature of Certitjid 1Vail Contractor Date
'ey signing this farm,I hereby certify that ilia xcti(s)ivas(ware)consinrcled In accordance
7.is this a repair to an existing well: Dyes or n No, ulth 15A NCAC 0?C.0100 ar 33A ACAC 02C.o20o Well Cansrnrction Standards and thot o
Ifthis is a repair;fill out bmauyr nvatl eonstntcrion infannotian and raplain the nature oftha cop)-ofthis record has been pravidul to the hell amen
repair under M21 remarks section or on the back of thisfornr. 3 Site diagram or additional well details:
S.Far Getspmbe/Fi1=T or Closed-Loop Geothermal i7da Uou may use the back of this page to provide additional wall site details or well
construction.only 1 OW-1 is needed. Indicate TOTAL o wells construction details. You may also attach additional pages if necessary.
drilled: ' 4.1 5 � '�� SL-3uY1iTTAL INSTRIlCTiotVS
9.Totnl 1i eil depth below land surface: 7-00 i ' e„mot n fty�$Slf)1 tFor All Wells: Submit this fonts within 30 days of completion of well
Fa•nuthip/e a olis list all depths fdUereat(example-3 f(_g200'and 2@10!>l�t construction to the foliowing:
`t DVVR Section
10.Statle water loval below top of casing: M) Division of Water Resources,Information Processing ilnit,
f nutter loi el is abovo casing,rise '+" 1611 Mail Service Center,Raleigh,NC Z7699-1617
11.Borehole diameter: {In.) 24b,For Infectfo it}`Velis: in addition to sending the form to the address in 24a
rotary above,also submit one copy of thisfotm within 30 days of completion of well
12.Wetf construction method: construction to the following:
(t.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ihTLLS ONLT: 1636 Mail Service Center,Raleigh,NC 276994-636
13a."yield(apm) Method of test: air pressure 24c.For rater Sunni-,,&Iniection Wells In addition to sending the form to
the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfectiontspe: granular Atuount ��Z completion of well construction to the'county Health department of the county
where constructed.
fonn Gti•L-1 North Carolina Department ci n%rimamental Quality-Division ofiV Resources
ator Resoues � Revised 2-,=-20 t6
r