GW1-2021-04725_Well Construction - GW1_20210527

For Intemai Use Only:
1,Well Contmetor-Information:
Chris Morgan
14:1V4TER ZONES
11'ell Contractor Name MON To DESCRIPT1O q
3572 rt. .
NC Well Contractor Certification Numbe.r fL ft.
Morgan Well & Pura Inc. 15..OiJTERCASiNGirormniti-casedwcUs ORLIIVER(tf. ^cable)
p+ IROIti TO DWIETER THICKNESS MATERIAL
Company Name +1 rt• ft. 6118 in. sd21 love
16.INNER SING OR TUBING(eotheimal closed-loo
2,Well-Construction Permit#: r•Ront To DIA6tETER THICKNESS MATERIAL.
List al appilcahle^ell consm two n penntts(r.e U1C,Carob:State.Variance,etc) fL
ft. in.
3.Well Use(check well use): ft• ft iu
"✓ater Supply Well: 17.SCREEN
Agricultural DMunicipal/Public IL rROM TO DIAb1E7En SLOT SIZE TH[CIQAESS AATERIAL
OG g Supply)eorherrrial(11cating/Coolin Su I J$Residential Water Supply-(single) tt in
QIndushial/Commercial ft. ft,
QlResidential Water Supply(shared) 18.GROUT-
Irrigation
Non=VltaterSupply Well: reoni To MATERIAL WPLACENIENTni>txoDrrAntounr
o fL 20 R' bentonite poured
Monitoring 011ecovery
Injection Well: ft, ft.
Aquifer Recharge oGroundwater Remediation ft.
Aquifer Storage and Recovery QlSalinity Barrier 19.SAND/GRAVEL PAC1Y(tfa licable).'
rROM1i TO MATERIAL EigPLACE0.1ENT'NIETROD
: .:)Experimental
OStormwaterDminage ft. ft.
Geoth tnentai Technology �ISubsidence Control
ft. ft.
Geothermal(Closed Coop) []ITracar 20.DRII LING LOG(attach additional sheets If necessary)
Gcothemlal(Heating/Cooling Return) ' : Other(explain under 021 Remarks) rtt°at To DESCRI oN cmor, artiness,satOmG:r c Stain sip erel
O a ft. � S ft. r �
4.Date Well(s)Completed- D We II rD1,n/a
.�r
5a.W'el. ll Location- A57 ft. rt,
�I/W I S nla s ft, �
Facili OtvncriVa c { Y 1
S5 Facility (ifapplicable) ft. tl,
ark ,� 11/aa�l a nl� ft. ft.
phy 1 Address,City,and Zip tt, f?.
itllt,{/1 n1a 21.REMARKS
U Ay
County Pamel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees
(if call field,one lat/lang is sufficient)
22.Certification:
35. �132 ,
V 21-. z
6.Is(are)the well(s)OPermanent or OT'emporary Signature of Ccrti11 ft<:d wall Contractor Dpfe
By signing thislarn.I hereby cerr,)5,that the tvell(s)was(were)ronstnicied in accordance
7.Is this a repair to an existing well: DYes or n IVo with
fdiis is a repair,fill wet 6rtowu well coastrr 13,1 NGdC 02C.0100 or 1511 NCdC 03C.0200 WWI Canrtnrctiwr Standards and that
rcrion infannatiwl aad etplain lire nuture ofihe copy ofthis record has been provided to the well owner.
repair under 421 rewari-S section or on the back ofdtis foml.
23.Site diagram or additional well details:
G'For Geoprobe/ElPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r
,,��//�� SUBYRTTA..L MST'RUCTIONS
9.Total depth below land surface: Zoo (fL) 24n.For All 'Webs: Submit this farm within 30 days of completion of well
I%arvnultipIO le a treNs list all deprlrs ifd�erenr(ernmple-3@100"and 2@1 UDC
/O construction to the following:
10.Static water level belOW top of casing: [�
Ifnuter level is aborecrosing,use +^ (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fin.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this!form within 30 days of completion of well
(Le.au_eer,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY-%'ELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 IW-ail Service Center,IR21eigh,NC 27699-1636
13a,Yield(glom) Method oftest: air pressure 24c.For Water SuDDiv&infection Wells: In addition to sending the form to
granular the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection t}pe: Amount: 0
adZ completion of well construction to the county health department Of the county
where constructed.
Parini North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016