GW1-2021-02433_Well Construction - GW1_20210527

Y,JWUJUu..u, 1-4aL.KUCTION RECORD For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.IVATERZONES i f
lVell Contactor Name MOM TO I DESCRIPTION
3572 ft. ft. I i`
NC(Yell Contractor Certification Number IS..QIITER CASING nor multi inset 1solls QR LINER it ncab10)
Morgan Well&Pump, Inc. FROM TO DtAM1ETSR TBICt—S MiATERIAL
Company Name
+1 ft. ft. 611a in. sd21 pvc
IkJ 2t +q� g6 I&INNER CASING OR RING(geothermal closed-loop)
2.Well-Construction Perini##' G�` �� rROMt I I DIAMETER I THICIWLSS I MS.tT1rRtu
List all appllcahle well constnrction permits ga UIC,Comgi:State,Parlance,etc.) fL ft. In.
3,Well Use(cheelc well use): ft. ft lo,
Water Supply Well: 17.SCREEN
FROM I TO --l—MANI&ER71 SLOTSiZE I THICIMTS5 I MLlTER1AI.
Agricultural DMunicipai/Public IL ft, In.
�Gcotherrnat(Heating/Cooling Supply) EllResidentiai Water Supply-l(single) €t. I 1n
Ml industriai/Commercial DResidential Water Supply(shared) iII.GROUT..
1nigation rROMi To a1AIERUL EMSPLACEMSEMNl THOD&AMOUNT'
Non-Water Supply Well: 0 ft. 20 ft. bentonne poured
. Monitoring ORectivery ft ft,
Injection Well: ft. ft.._ Aquifer Recharge DGroundwaterRemediation 19.SANAIGRAYJrLPACICifa licnbla).
Aquifer Storage and Recovery OlSalinity Barrier FROM TO MrATERFAL EMSPLACF.aIENTMErsoD
Aquifer Test 0stormwater Drainage ft. ft.
Experimental Technology QlSubsidence Control ft. ft
Geothermal(Closed Loop) QETracer 20.DRIB ING LOG(attach additional sheets If necess )
Geothermal(Heating/Cooling Return) FlOther(explain under 021 Remarks) I FROM To DESCRt ON color,h rdnem salyrocit t c,nrata e=etc.)
Q C7 ft. ft. TzeJ DR
4.Rate Well(a)Completed�" Well ID r n/a S # 0 ft- *a'��,�
Sa.Well Location: 3v ft. SO4 It.
9 _V fu t"i6 m s nla ?100 ft. &o ft.
Foriliry/OwnerNaame \ �J �j Facility iDr(ifapplicable) R' R'
41i/0` tt-"e J t "( l kD M4;'J C,/— ft. ft
Pinysica!Address,City.and Zip
it. ft `
21.REnt1AMCS
%v l
County Pascal Identification No.(PM
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v r,
(ifwall field,one ladlong is sufficient) ,A7r� 22.Cerjtification-
J 6.Is(are)thewcl1(s)0Permanent or [Temporary Signature ofCertifj(rd well Contractor ate
6J1 signing this fonn,I harebp certi,that lite ucll(s)ivas(were)constntcted in accordance
7.Is this a repair to an existing well. Dyes or n i4o with 15A NC4C 02C.0100 or 15.1 NCAC 02C.0200 Well Construction Standards and that a
jthis is a rapair,fill out known soull construction infannatlon and canlain the nature of the cop},of this record has been provided la tha'till/onmcr.
repair under Q1 rentarla section or an the back of thisfornt. 23.Site diagram or additional'tvell details*
8.For Geoprobe/IIPT 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-1 is needed. Indicate TOTAL NUMBER of velis construction details. You may also attachadditional pages if necessary.
drilled: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a.For All Wells: Submit this form within 30 days of completion of well
Fa•nunldple wells list all depths fdVerent(example-3@200'and 2 a 1001 construction to the following-
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
Ifnater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 CID) 24b.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 WATER SUPPLY D+TLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 2dc.For hater Supply&Injection Wells: In addition to sending the foam to
13n.Yield(gpm) Method Of test: Injection
address(es) above, also submit one'.copy'af this form within 30 days of
13b.Disinfection tope: granular Amount• f71J completion of well construction to the county health department of the county
where constructed.
Forst ow-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016