GW1-2021-00992_Well Construction - GW1_20210419

RECORD,LqW.11 For Internal Use Only -.: .: ...
I.Well Contractorfntbrmattim:
Chris Morgan 14.WATERZONES
11'ell Contractor Name mom TD DESCRIPTION
3579
fk. E
NC 1Yeil Contractor Catification Number ft.
15.Otr MR CAMNG fror multi cased ive2ls OR LWER gr ncabla
Morgan Well, Pump, inc. rxont Tv olZ, TER THICtfNESs n7nTER7AL
Company Name +1 ft. S7 tt. g 1!g ia. sdr2t pvc
ry 16.INNER CASING ORTURING(geothermal closed-Iao
2.Well'Construction Permit 0.— ego p�0a.. FROnt I To DIAbrETER I THICIMP-gZ I aln-MRlnl.
List all opplicnithe tnell constnction p—its A r-UIC,Corngr.State.1'ariance,eir-) FL fG in.
3.Well Use(check wet I use): ft,
Water Supply Wall: 27.SCREEN
FROni TO D1AnIETF.R SLOTSIZE TRICItr'ESs hfATERlAL
Agricultural DMunicipal/Public ft
ft.
Geothermal(Hcating/Cooting Supply) j&csidential Water Supply-(single) tt. R.
�3Industriai/Commercial Olkesidential Water Supply(shared)
38.GROUT.
It7lgatiori FROM TO A7nTERL1I tMPLnCEntENTilirruoD&AMOitn7
Non�Water Supply Well: 0 R' 2a R• bentonite poured
14anitoring Recovery fL ft.
injection Wall.-
Aquifer Recharge ft. ft.
g OGroundwaterRemediadon
Aquifer Storage and Recovery iSalini Barrier 19.SANDlGRAVEL PACK(if a ticable)
FRODr TO MATERIAL V FAIPIACF IEN''TbrETHOlo
Aquifer Test DStormwaterDrainage ft. ft.
Experimental Technology QlSubsidence Control ft. tt
Geothermal(Closed Coop) QtTracer 20.DRn ING LOG(attach additional sheets if necemar4'
Ocothcrmal(Heating/Cooling Retain) Other(explain under 021 Remarks) t,FROM To DESCRn'TIO- Color,harda¢ss.solifrucli I C:Jain size Cie)
4.Date Well(s)Completed: 2 tip Well HN"r n�� 'd ft. c
So..eW-ell Location:
J
CSS*C4 !t'ivan V 0 nla era ft. e _ r
Facility/Owner Narrc Facility ID"(ifapplicable) fL ft
Physical Address,City,and Zip ft. frTIP
�e,tr+M -t S n/a 21.RENtARIG5
County Parcel Identification ito.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifavell field one lat/long is suffrcicnt) li �t " tr°��1 "a.
22.Certification: V u l
6.Is(aro)the woll(s)OPermanent or OTemporary Signature of f i Ccru t tvc1l Contractor Dale
By signing this Brut(.I hereby cerlih that the wall(s)vt=(were)constructed in accordance
7.Is this a repair to an existing Neil: Dyes or n No frith 15A NCdC OIC.010D or 15A AvCAC 02C.0300 Well Construction Standards and that a
If this&a mpair,fill out xmov>nt well constnrction infennation and ea-plain the nature of the copy of this record has been provided to the hell auger.
repair under#21 ratnarkr section or on the back-of this forni. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW I is needed. Indicate TOTAL NUMBER of halls construction details. You may also attach additional pages if necessary.
drilled:! SbBiMTTA-L MIIS'i.RUC TIONS
9.Total well depth below land surface: aU ( 1 24a.For All Wells: Submit this form within 30 days of completion of well
ror nntltiple;tells list all depilts trdorerent(e-ratnpte-3@d0a'ond 2@J00') construction to the following:
10.Stntic hater level below top of casing: 4J a (fur) Division of Water Resources,Information Processing Unit,
If raster heel is above casing,use"+" 1617 Mrail Service Center,Raleigh,NC 27699-1617
!i.Borehole diameter: (in.) 24b.For Ialection Wells: In addition to sending the form to the address in 24a
12.Nell construction method: rotary above,also submit one copy of this farm within 30 days of completion of well
(Lt.auger,rolary,cable.direct push,etc.) construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY' 4TEi.LS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 5 Method of test' air pressure 29c.For Water Suovly&Illiection Wells: In addition to seading the form to
ranular the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. 9 Amount: `Z 1 o Z completion of-,veeiI construction to the county health department of the county
where constructed.
Form Gust-1 North Carolina Department ofEnvitonmental Quality-Division of Water Rcsoures Revised 2?n-2016