GW1-2021-01295_Well Construction - GW1_20210329

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I.Well Contractor Information, For Internal Use only. -- - -
Chris Morgan
well Contractor Name 14.)i'ATERZDNES
3572 ONE TO oEsc t rrlON
ft. R.
NC Well Corluactor Cmificadon Ntmtba
R. R.
Morgan Well & Pump
inc.
F6, TJTER CASING(for mW@iIN wens ORLWER Rf Ilcable)Company Nome FRONT TO D44arEfER
+1 fL iHIClOJEss MATERIAL
?,WolfConstrucHnn Permit 4: 16.INNER CASI GORTUetNG( errrm clost p
etl-lo pvc
Lur all npplicalr(e W110.1w"caaa ae )� FRONT TO
eeth l
r 0/C,LaMar.Sate I—act,A clef f4 DIANIEfER THICENESS N7:17ERLLL
3•Well Use(check well use): R in
Water SuPPIY We11: fL ft. in.
ElAgriculnual 17.SCREEN -
[pMunicipal/Public FRONT TO DIAMETER�Grothermal(Heating/Coolin Supply) rr. sLoi st2E rnJetm'Ess N an
B PP Y) QlResidendal Water Supply(single) ft. la
�[ndustrial/Commercial {r,
- water Supply(shared) ft.
fiti JlResidential W
oetion 18.GRODT
Noll-Water Supply Well: FRONT To
NTATER[AL ENIPLACEN1EhT NTEfHOn egnlDun-r
14(onitoring Df'-�7I, o IT. R,
Injection Well: L1Recovcry bentanile poured
FL Aquifer Recharge IT.
tr• ft.
Storage and Rerovcry Groundwater Remediation
QlSaliniry Barrier 19.SANID/GRAVEL PACK to MCI
LAquifer-resE FROat To MATE GL
QlStarmwater Drainage {imental Technology R.ermal(Closed Loop) QlSubsidence Control
(t. ft.
cmlal(HeatiaglCOolio Return 0ITTaeer 20.DRILLING LOG(attaeh additional sheets if necess
B ) other(ex lain under;2l Remarks) FRONT To )
mSclUMON(culo.hurdacu,uouracar c,en[a-uc cic/
•l.Date well(s)Completed: nj8 v C0' ft,
Well IDR—_ C R.
6a.iVcll Location: Ir..t-.
D0jai ij
9 �.�' ft. 30 R.
n/a LO
Facility/Gwncr Nomc J t IG R. l rki I Iel
3/ (i Facility IDp(ifapplicable) I(O r
%
RA ft. H/
7-7
Physical n •
Address,CiO�,
d �(SN R.
Cuumy n/2 -'1•REVARICS
Pamel IdaNUfi tan No.(pIN) y
Sb,Latitude and longitudec degrees/minutes/seconds or decimal degrees:
(ifwdl field,one laUlong is sufficient)icnt)
35. 99
DD((JJ ---_W _
6.Is(are)the WOU(s)OIY. permanent /� ��/�) 5 C'
ar QlTcmporary 5 gn N fCcmf�ad well Contractor ^ J
Omc
2Is this a repair to an existingr['e0: D Q 3l•signing dlir 02C f 00 or cerriry" that 2 "I//s s
'f'Pd Cs o rapaiq fll or kmoun wc'lromlmcrian tnJ nuaTion and r1P aiu!lie"vanz ojlLe caP)'oflhir rerordh¢r been pruvidedra rGe wall aumen�f', ��rn¢led in aced,ha,.
'id+IS"N'CdC a1C.d1aP or liA NG1C 02C.a20a(Dell Comm¢/!mr Standard:mat that o
repair wider.21 mnmrLt saeTioa or an the Lack aflGis(ornr.
I.ror Geoprobe/DPT or Closed-L 23,Site diagram or additional Well details:
conswctio Only I OW- . iu Geothermal Wells having the some You may use the back of this page 10 provide additional well site details or well
0. Y I is needed. ]ndirnte TOTAL NUMBER of wells construction details. You may also attach additional pages if neressarv_.
drilled: '
9.Total well depth below land surface: LUNrTTA-L INSTRUCTIONS
For pullipl,"Ills llstalldcpdu/YoI remalpfe-3@Q3o0 1112TI (Y) 24a. For All Wells: Submit this form within 30 days of completion
10.Static water level belmv top of casing: I p construction to the following: of well
Ifnurer(ere/is above cvsfiig,«se"+" M) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 2 7699-1617
rotary (in.) 24b,Far Injection Wells: In addition to sending the form to the address in 24a
0 a auger,mtary,cable,dims push Well construction method: ------ above, also submit one copy of this form Within 30 days of completion of well
(i.e. etc.) Construction to the followina:
FOR�VSTER SUPPLY WILLS ONL i': Division of Water Resources,Underground injection Control progra
�t 1636 Ya m,il Service Center.Raleigh,NC 27699-1636
13a.Yicid(gpm) Ylethod otrest: air pressure ,a e For Water Suooh'r Iniection iirells: In addition to sending the form 10
13b,Disinfection npe: granular 'l n the addresses) above, also submit one copy of this form within 30 days of
Amount: c� /`.) completion pf well constructed. construction to the county health deparunent of the coun[,v
where
fonn G'A'-1 Notth Camluia Depxrrmcat ofEarimamenml
Quality-Division oMawr Rczourns
Revised 2-2?-2016