GW1-2021-02670_Well Construction - GW1_20210527

(GW i) Forintemal Use Only: _- _.........__...
1.Well Contractorittformation: j
Chris Morgan
19:>i`ATER NE
w ZO S
well Contractor Name FR0111 TO DESCR1PTl0iv
3572
NC well Contractor Certification Number ft ft.
i
Morgan Well et pump, Inc. 15..0IITERCAS1tVG(formul11-cased wells OR LINER(tt. ncablc
IROM11 TO DIAMEMP Ct4YE5s n2nTERIAL
Company Name +1 ft. ft. 6118 tn' sdr2i
pvc
�n/_ IG.INNER CASING OR TUBING(eotheenial dosed-too
2,Well-Construction Permit#: ✓vw r•Ront TO DIAIHEriz THICKNESS n��TSRI,u
List all appllcahle will constntction permits a a UiC,Coogr.State.Var(ance err) ft ft. in.
3,Well Use(checli well use): ft.
tt. to
17✓ater Supply Well: 17.9
Agricultural DMunicipal/Public FROM TO DIADIETER SLOTStZE TH[CtQ�ESS hLiTERIA!
QGeotherrnat(Heating)Coolino a it ft In.
Supply) (�IResidential Water Supply�(single)
01ndustrial/Commercial
DRes ft, ft. in.
idential Water Supply(shared)
filiation 18.GROUT
Non-Water Supply Welt: Fnon1 TO r11ATERLIL EhiPLACEN=.N7M11L•?H0D&AnrOunT
0 fL 20 ft. hentanite A4onitoring ORecovery poured
I
njectionell: fL ft.
echarge oGroundwaterRemediationorage and Recovery QlSalinity 13arrier 19.S AiVD1GRAYEL PACK lift llcablc).
Aquifer Test FRONT TO MATERIALE EM1IPLAC011ENTNIFT110
oStormwater Drainage ft. ft.
Experimental Technology QlSubsidence Control ft. 1r
Geothermal(Closed Loop)
0 ITracer
0.DRILLING LOG(attach additional sheets IFnecess )
Geothermal(HeaHng/Co)ling Return) Other(explain under,021 Remarks) �OM1I TO nEscetPTtoN color hartlarss soJl/rncl:t geraJoirar eteJ
t7 ft. ZD ft. it d i f
4.Bate�Well(s)Completed:�2f 2 Well rM.n/a a
rowh -W
Sa. ell Location: 35 ft' �S ft, Y oC
n/a �rS 1r. Z O rt. �'
Facility/OwnerNamc V T Y0.�I `G
Facility (ifappIi cab Ic) ft. ft.
h. f✓ ft.
Ph sical Address,City,and Zip ft. ft.
>n n/a 21.R>;rr lcs
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �T;Ori
(iftvell Feld,one la one is sufficient)
22.Certification:
Al
6.Is(are)rite tel(s)kPetmanent or Oiemporaly St f t Ed vc oauacmr Dat
7.Is this a repair to an existing well. By signing aus•form.I hereby cart jj:that Ithe sscll(s)tvas(were)ronstntued in accordance
Ifthis is a repair,fill oul6•nown well eorstnrctioni fonnatiou and a Plain(!re nature of the c m,of 1 is record7h as ben pray dell io or 15A �c well anme Well Conrtnretiau Standards and that a
repair urrder A21 raoarkr section or on the back of this form.
23.Site diagram or additional well details:
G-FOr Geoprobe/DDT 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 wells construction details. You may also attach additional pages if necessary.
drilled:
SIJBIWIT T R1 IlVSTRUC T IONS
9.Total well depth below land surface: (fu) 24a. For All C4
For rnrdaple tralis list all depths Wefts.- Submit this farm within 30 days of completion of well
ifdierenr(arample-3@300'and 2@100�
construction to the following:
10.Static water level below top of casing: 3� (ft.) Division of Water Resources,information Processing Unit,
(f rater level is above casing,use ,+,,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
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.auger,rotary,cable,direct push,ctc.) construction to the following:
FOR WATER SUPPLY ors 1,LS ONLY' Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(0111)_1_ Method of test- air pressure 24c,For Water SuDDIv�irtiectioz(�4'eils: In addition to sending the form to
136.Disinfection type:
granular f Z t3Z the address(es) above, also submit lone copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Fonn 0W-1 North Carolina Department of&%,ironmental Quality-Division of Water Resources
Revised..2�.-22-�_O16