GW1-2021-04254_Well Construction - GW1_20210419

For internal Use Only: -
1.Well contractor Information:
Chris Morgan
Wall Contractor Name 1`l•W9TERZUNES
xfl3T�
DFSCRlPTIOiti
3572 131
NC 1Ve11 Contractor Certification Number • i
Morgan Well&PUI11p, inc.
15..O1 [ER CASINrs form DI cased t'vetls OR LMR or ncable
rxon[ To DtAntETER TEUC[Ons ntnTEtiL1L Company Name +1 R• ��ft. 6Ila in,
Y�1 G sd2,
2,W011'CRnstruetion Permit#: 16.tNNER CASING OR TUBE titG(eotheiaaat closed-loo
pvc
List all applicable ,ell constnrctlon pROnt To DIA51MR THICI{NESS Pernuu'h•a U/C,Corrn(r;State,Parlance,etc, n. ft in.
3.Well Use(checkwell use): ft.
IL to
lhtater Supply tTtlell: 27.SCREEN
Agricultural oMunicipaL/Public cRont To D1AntErER s[.orstzs TH[ctrn n iTER1AL
Pccothermat(Hcming/Coolkn IL
n' 1n
g Su i PP Y) �tesidendal Water Supply'(single)
Dindusttial/Commercial D ft.
Residential Water Supply(shared)
ini ation 10.GROUT.
on-Aklater Supply Well: rttont 'ro MATERIAL ENIPLACenti NMAETHOD&AnlooN'T
OlMoniloring 0 R 20 bentonite
IRCCovery poured
Injection Well: fr. fr.
Aquifer Recharge oGroundwaterRemediation fr. tt.
Aquifer Storage and Recovery QlSalinily Barrier FRONT
SAND/GRAVEL nialica ic)
Aquifer Tes[ Futons To L EM1tPI ACr•.M1TENTM1tETHOD
[�IStomlwaterDrainage ft. R,
Experimental Technology E]ISubsidence Control
Geothermal(Closed Loop) ITlacer ft, ft,
20.DRILLLNG LOG(attach additional sheets if necessary)
Gcothcmtal(Heating/Cooling Return) Other(explain under;.21 Remarks) FRO1i TO DESCRIPTIOti w1or,hardness soinroda n etala slur eras
ft. O ft.
d.Dote Well(s)Completed: —Z. "Z Well IDir nla I Q (t, *30
ft.
Sa.Well Location;
SV<--aA Sena .r {r- nla (V rt. rt.
Factliry/Otvncr Namc Facility ID"(if applicable) 9 ft. ft.
S'3�a CA&IA GA I��napblt"S ft. vc, r
- ft,
Physical Address,City.and Tip ft. ft.
°wSn 2`f6 37Ff 21.REMttRlcs y,,
County Parcel Identification No.(Pnq
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Feld,one lat/long is sufficient) (�
22.Certification: Uilit
W �r nip
6.Is(are)the wall(s)oPermanent or oTemporary SignatuTo of Ccrti99d hell Contractor
Dare
7.Is this a repair to an By signing this form.I hemby certify that the uall(s1 rear(were)constrrteted in accordance
p existing tyell: Dyes or n No trills 13A NC4C 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill ont known tce11 constmction infannat(on and explain Ilia nuture of the copy of this record has been provided to the well oumer.
repair under tUl remarks section or an the back of thisforul.
23.Site diagram or additional well details:
G.For Geoprobe/DPT or Closed-Loop Geothermal lVells 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 wells construction details. You may also attach additional pages if necessary.
drilled:!
STRUC
9.Total well depth below laud surface. _Z d
Slj'Bi 1"i.T T A-L IN T IONS
Rarmirlrlple xel/s list all depths tjdUrerenr(ararnple-3 a Z00'and— IUO� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following
Tit far le hater level below fop of casing: tJ (ft.) Division of Water Resources,Information Processing Unit,
ijnnterlcrel is above casing,ruse"+"
1617 Mail Service Center,Raleigh,111C 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection IVells: 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY%TMLS ONL Y: Division of Water Resources,Underground Injection Control Program,
1636 IVdail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnl)--6— ___ Method of test: air pressure 24c.For Water SRDDIv Infection Wells: In addition to sending the form to
13b.Disinfection type- granular � the address(es) above, also submit'one copy of this form within 30 days of
P ' Amount 'L. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmenial Quality-Division at water Resource' Revised.,-..2,.-..
s � 2�
� 016