GW1-2021-02722_Well Construction - GW1_20210527

MILL fl::+l N8TRTJrTT0Nr It1C®Y� . ....�......
(G 11 Forluternal Use Only: i _..-._.._... _........__...
L Well Contractorinformation:
Chris Morgan
14.tiVATER ZONES
Well Contractor Name MomTO DESCRIPTION
3572 fL rc.
NC Weil Contractor Certification Number R ft.
Morgan Well&Pumn' inc, iS..OUTERCASfttiG[EormttlticnsedtvcUS ORLiT1ER tf ncabto)
IROM TO DUAIETER THIC[QVESS MATERIAL
Company Name +i ft. 0 ft. 6118 ' t° sd21
pvc
2,Well'ConstructionPermit#: (p I(p .INNERCASING
16 ORTUBING(eothermnlclosed-loo
FROM TO DIAMETER THICIWESS MATEW-1,
List all applicable will constriction parrots(r,e UIC,Connh'.State,Variance-etG) ft. ft. im
3,Well Use(checl.well use): ( ft. ft. la.
61"Agricultural
17.SCREEN
oMunicipal/Public EOM TO DIAM1IETER SLOTSIZE THICIQCESs nL1TERtAL
Geothermal(Heating/Cooling Supply) ®IResidential Water Su 1 -sin le ft ft. In-
Dindusttial/Commercial pp y( g ) ft• ft. in
QlResidential Water Supply(shared)
I111gatl0n 10.GROUT.
Non-Water Supply tlr/eli; FROi1t TO '11ATERL'tt EhiPLACEM1iLrT_METHOD&allot]
0 tt Za R' bentonite !
Monitoring ORecovery poured
Injection Weil: ft. ft
(Aquifer Recharge DGroundwater Remediation fr.
:(Aquifer Storage and Recovery QlSalinity Barrier i9-
SAitTD/GRAVEL PACIC(ifa licable).
Aquifer Test
FROM TO MATERIAL EMPt.ACEM1tENTatETHOD
OStormwaterDminage ft. ft.
Experimental Technology QlSubsidenae Control
ft. ft.
Geothetinal(Closed Loop) QlTraeer 20.DRILLING LU@(attach additioaa!sheets if necessary)
Gcothcrn)al(HeatSng/CoOling Rettim) Other(explain under 021 Remarks) FRnOM TO 1 DESCRIPTIotr• emo,hardness sallltvdt K a era)o s'tk etc)
V ft. �...) ft. y'
d.Hate Wells)Completed: 30 oZl Well M1_n/a EWO
ftSa, ell Location: I�/15ft.� r�n/a ft. \ Yt�n
Facility/ tvncrNamc FacilityMi (if applicable) ft. ft.
ZVs Ellis , tab `/
vda I c Z81 ft ft.ph sical Address,City,and Zip ; a"
ft ,
�Dl0�,V1 n/a z1.ItErra.Rtcs
roAl
County Parecl Identification wo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: til3il I t
(ifwc[I field,one inUlong is sufficient)
�,o .�; n
35,^� o. _ O.`',dG! 45 22.Certification:
/ N O `�t W i
it a
6.Is(are)the wells) Pcr3ranent or QlTemporary Signahtre of Carttfj�'d Nell Contractor D tc
7.IS this a repair to as existing well: By signing this toms.I hereby certh6 drat Ilya teal/(s)tvas(tinere)constructed in accordance
Dyes or n No nvth 13A NCAC D2C.0100 or 15A NCAC'02C.0200 Well Consnticrion SrandaMs and than a
Olds is a repair,fill out known tvall construction infannailan and emlain the nature ofthe copy ofthis record burs been provided to ilia well oumer.
repair under'01 rentaria section or on ilia back of tbisforni.
23.Site diagram or additional well details:
E.For Ceoprobe/FDPT or Closed-hoop Geothermal Wells having the same You may use the back of this page to provide additional wall 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: '
SL-3WE rTAL INSTRUCTIONS
9.Total well depth below land surface:
liar mrtltipla hells list all depths fdii erent(emtnple-3 ri 200'ond I a 100 (`) 2�Fa• For All Wells: Submit this form within 30 days of completion of well
C construction to the following: p
10.Static oyster level below top of casing; 34S (gt)
lftt'ater leral is above cursing,rise + Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 m.
( ) 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,etc.) construction to the following:
FOR W-4,TER SUPPLY-%'ELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centor,:Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SUDDiv&Iniectio I Wells: In addition to sending the form to
granular �7 the addresses) above, also submitf one copy of this form within 30 days of
13b.Disinfection type: Amount: G.O completion of well construction to the county health department of the county
where constructed.
Fomt GW-1 North Carolina Department of Environmentzl Quality-Division of Water Resources
Revised_�_�2. 2,_�
016