GW1-2021-00587_Well Construction - GW1_20210205

nr A AV.W,e„SL JL.�L.FL l LA3:t+t.rYX1fB.$3� =�.3 For Inteernai Use Qllty: .
-.Well Contractor Information:
Chris Morgan 14:1ir4TERZor1Es i
itrall Contractor Name FROA To DEsc urnop;
3572
INC Well Contractor Certification Number
CASTNQ tMor mute-cased tvc114 OR LU ER ra Itcablo
Morgan Well�Pump, Inc. FRo;+t Ta DG111fETER THJCKIVESS 1fnxERtAt.
Company`ante +1 ft. ,3 ff. ti 1ia in, sdt21 puc
16,INNER CASING ORTUBING( eothermal closed-loo
Z.Wcll'ConstrUction Permit rt:_ FRoilt Ta DIA6i£rCR Tti1CtCNLSs ar,ilLRt!!t
Ustall applicable u211carrsirrrctionperreirs(ie.UIC,Catratt:State.Yatianc etc] R ft in._
3.Well Use(checkwell use): ft. ft, In
Water Supply Well: 17.SCREEN
Agricu}turaf FROhf TO DtA4I__ SLOTSI2E THICIENTSS hL1TEtttAL
BlMuniaipal/I'ublic is f:_ In.
Gictthermat(Heating/Cooling Supply) @lResidential Water Supply(single) ft, ft, in.
industrial/Commercial DResidential Water Supply(shared)
IGT..tlriaatite To NIA'iERIAL ChtPIACF&SENT"'.IFiOD&AtttOUN"r
Non-Water Supple]Well: zo ft. bento the poured
i�'tonitoring QlRecovery fInjection lfe ell:A uifer Reehar a •q g oGroundwater Remediation
Aquifer Storage and Recovery ! ISalini Barrier IGR V_RL PACK 1fa ltcabie).'Q iy TO AtwTLRrAL lethl t.ACr•.RtENT lS£TriOD_ AquiferTest OStormwaterDrainage . ft.
Experimental Technology olSubsidence Control ,Geothermal(Closed Loop) o)lydczr ING Lt lG tattoeh additional sheets if accessCcothcr mat(Heating/Cooling Return) Other(explain Dnder;:21 Remarks) Ta osscRtrTto v color hrd sofUroch t e.erata s'r�e•eie)
. ft.4.Date Vvell(s)Completed: Weil ID#n/3 ,Sq.Weil Y�oeation• . � ft.
FariltrIlOwnu UNtme Facility TDP(ifopplicabie) L gsft. I L6Sft- brbA' fac
Sc�, 6oiic alrt� lV� _z$Uc�-� USft. ti ,ft. b�vc t'wrt(t>_
P iyskal Address,City,and Zip ft, ft,
i
U n1a 2I.R>;D7ARILS
County Paivol IdcmificationNo.(PIN)
5b.Latitude and longitude In degreesltninuteslseconds or decimal degrees:
(1tweli field,one iatilong is sufficient) 22.Certification:
�.`A*33��j�1 l+i `i C� f 7.47 W ' lt"_
6.Is(are)the well(s)OPermanent or O semporary Signatum ofCcrtif@il Well Contractor Ddic
By signing this fonn,I hembit certO that the urll(s)was(here;constnrcted!n accordance
7.is this a repair to an existing well: Dyes or 21No frith ISd NCdC 01C.0100 or ISd NCdC 02C.0200 Well Camorrtctiou Slandards and that a
!'this is a repair,fill aid known well consa trction information and explain ilia nature ofthe cupF ofthis record has been provided to the well owner.
repair under n31 remarks section or on the back of thisforn>
2 diagram or additional well details:
8.For Geoprobe/DPP or Closed-Loop Geothermal Wells bavima �♦� jetUAy use the back of this page to provide additional well site details or well
construction,only 1 GVtt 1 is needed. Indicate TOTAL,NUMBE construction details. You may also attach additional pages if necessary.
drilled: '
�j 1�a'TTAL M-17RUCTIONS
9.Total well depth below land surface: >(� F�d V Mot.&I Al Wells: Submit this farm within 30 days of completion of well
i%ornuthipla wells list all dapths t'dLereta(erampte-3@200"and 2@1001 n pTOGS tta following:
10.Static water level below top of casing, �� 15'r O'f nro J ��lOn
P l;' ._.._�.F.r. � Division of Water Resources,Information Processing I1nit,
ljweter/ernel is above cxrsia use"." 1617!Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. (in) 3hb.For Infection Wells. In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form 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 WATEi2 SUPPLY WEI LLS 01%LY-. 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a,Yield(;pm) Yethad of test air pressure 24e For Water Sunni%'&Injection i 9trelis- in addition to sending the form to
�} the address(es) above, also submit one copy of this form iv"ttbin 34 days of
13h.Dismfection type: granular Amount: /262 completion of well construction tot the county health department of the county
where constructed.
ih
Fonn OXV-1 North Carolina Department of Enviroamcntal Quality-Division of Water Resourcas i Reviscd 3-22 3atb
{
j