GW1-2021-00641_Well Construction - GW1_20210205

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1.Well Contractorlrlformation:
Chris Morgan 14.WATER ZONES
FRoM m DFSCMMOt4
ttrcII Contractor Name ft. [t
3572 ft. I rt.
CWellContractorCertificationNumber 1&ZDTERCASTEqG armmaensea.veus ORsnt�ttctfn licabt0
Morgan Well&Pump, Inc. • OMt TO DtAMtETER TMCiavEss M1ATCMAL
i ft, /0 1 rt. 6116` in, sdu21 pvc
Company Name1G.INNER CASING ORTt BING(eotherm¢I closed-loa
Z.Well-Construction Permit M 2 p FROM I -to DIaMIETER Ttuctcr ESS NVITERIAL
ListaN.appltcahle rreticonrtrrtction permits(i,c UIC,Cottntt:State.Variance.etc) ft ft. in.
3,Nell Use(checkwell use): ft. ft. in.
LMSEK
Water Supply Well: FRO- TO DFAMIETER SLOTS17 THICIMESS I MATERIAL
• Agricultural OMunicipal/Public ft ft In.
Geothermal(Heating/Cooling Supply) aResidential Water Supply-(single) ft. ft.
kIndustrial/Commercial DResidential Water Supply(shared) 19.GROUT
i _
tnigation FROM I TO I MATERIAL- EMIPLACLM1ENTaiEMOD&AMOUNT'
Nou-Mlater Supply Well! a n 20 R•. bentonite poured
Monitoring ORecovery
InJcctioa Well; ft. ft
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recov t 19.SANDIGRAVEL PACK fi licable).�
q g ery OlSalinity Barrier FRONT To I MiATERtAL I Et,IPLACF.Ar NT METHOD
A uiferTest Qi g R ft.
q StonnwaterDraina e
Experimental Technology [31Subsidence Control
Geothermal(Closed Loop) QlTracar 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRiMtOty color,hardness,solltrath! o,elate SIZE etc.)
Geothermal(HeatinglCooling Retuurrin) it _ Other(explain under 21 Remarks) C1 ft ft.
4.Datc Wells)Completed: 1 l f!'r well M#n1a t 5 IL rt. Y �
Sa. 'Nell'vacation; 3 S ft, `J ft.
aJ 6o, Vr te-f tG'tY ,i n1a rt. �t%hl{
Facility)OwncrName Facility IM(ifappiicabie) ft. ft.
o k Mc no
Ph}rslcai Address,City,and Zip .
ft, ft.
Ln1a 31.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miautesiseconds or decimal degrees:
(ifiveli field,one Iat/long is sufficient) 22.Certification:
LIP-
6.is(arc)the Tvell(s).oPermanant or oTemporary signatum of certirj�d"Vcll Contractor Date
B.1,signing thisfron'a,1 hereby certo that rite roofs)was(were)canstntcied in areardnnee
7.Is this a repair to an existing well: Dyes or EINo
trith 15A NC4C 02C.0100 or 15.4 A'CAC 02C.0200 Well Constntaian Standards-and that
if this is a repair;fill a i E7tou»rvafl canstntetian(njonnatiaa an �iCLEIN 1p r°pp ojthis record has been pravida, to the well oumcr.
rapair undar ff3I rentarkr section or art the hack of this jarn> 23,Site diagram or additional well details:
S.eor Geoprobe/M or Closed Loop Geothermal Wel ;,�av,��uua e�sa You may use the back of this page to provide additional well site details or well
constrcteo%only 1 GUr I is needed. Indicate TOTAL 1*R RifSBR �r'klt �2t construction details. You may also attach additional pages if necessary.
drilled: ` ation processing U ffiffli/i_ln^TAi INSTRUCTIONS
r Yo�f=,
9.Total well depth below land surface: L sadiM Mo.For All NVells: Subunit this'fxrsn within 30 days of completion of well
iron nnikipla%vells list aft depths ijd yerenr(erampte-3(D200'and 2C construction to the following:
10.Static water level below top of eaelti: (£t.) Division of Water Resources,Information'Processing Unit,
trimer level is above casills,use 1617 bail Service Center,Rnleigb,TIC 27699-1617
ii.Borcktole diameter: (in) 24b.For Injection Wells: b addition to sending the form to the address in 24a
rotery above,also submit one copy of this farm within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY AT LS ONLY; 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Methad of Test• air pressure 24c.For rater SuDnie&iniectiokn Wells In addition to sending the form to
// the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: granular Amount. !lLj d� completion of well construction to the county health depamnant of the county
where constructed.
Form OW-1 North Carolina Department of Enviroamenmi Quality-Division oflVater Rasourees Revised 2 22 2016
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