GW1-2021-01307_Well Construction - GW1_20210329

.aa N u Lri�l�'J ggUC1g0NREC®RD r-'"7 .......
For Internal Use Only.
I.Well contractor information:
Chris Morgan
t`l1 Contractor Name 14.WATERZONES
3572 rRonl To DESCRIMON
R. R.
NC"Yell Contractor Cenificadon Number ft. ft.
Morgan Well & Pump, Inc. 15.OUTER CASING for mW&rosedwcRs OR LMERnf2 Itcablu)FR051 TO DIAAIETER TEUCI04E9S afATGRV.L
Company Nanle +1 ft. ft
?,l /� 6118 is sd21/I'' /�(� �r �� to.INNER CASING OR In _._, eothermal closed-loo pvc
2.WdfConstrucHnn Permit d: C7 J 5 J
Liu all applicable usllcoosfnrcllon FRON TO DWISTER THICKNESS
pennirr(i.e UIC,CattnO:@fa(e.Parrnnce,etc) y n41TER1AL
3.Well Use(check well use): R• in.
Io.
Water SuPP1Y Well: ft. R.
37.SCREEN
Agricultural E)MunicipaVPublic FROM To DIMiETER SLOTSIZE
RGcothemte((3ieotmgtCOolln supply) ft. ft. In. TIC 'ESS nrATERInL
g PP Y) �IRrsidendnl Water Supply(single)
plihdust Commercial QlResidential Water Supply(shared) ft
- fin fltion on 18.GROUT
NUII•Wnter Supply Well: FROM TO atA7ERfAL
EaIPLnCEatENT METHOD E AMOUNT
Qhbloniloring o R' zo R• bentan s,
ERecovcry poured
injection Welt: ft. R
{Aquifer Recharge Groundwater Remediation ft. f
Aquifer Storage and Recovery EllSallniry Barrier 19.SAND/GRAVEL PACK if2 liroblc
AgUifer Test FROM TO M1inTERGL
Experimental echnolo QlStormwaterDminage ft. ft' F.M1IPLACLM1IEAT at ETHOD
Tgy
QlSubsidence Control ft
Geothermal(Closed Loop) QlTracer ft.
Geothermal(Heatinglm ''-0.DRILLMG LOG(attach
Conlin.Return) additional sheets Raeressarv)
Other(explain under r2l Remarks) TO DESCRIPTION(cola,bartlaeu,soi0mchl gamy d Well(s) shC,
C� ft• R. I �Y E"
.Date ell(s)Completed:� ' Welt IDR n/a
alr.)
Sa.Well Location:
' fit. L
r n/a ?5 h• It ,
Facniry/Owner Nam, C L'YG_N l r�y
Facility toP(ifapplirable) R. ft,
dd Cr YYiLWI H ! tl�� l t //C � � rt. rt.
Physical Add ,Cny.and L1
�ty1.(CIIA n/a 21.REMARKS -. .
County
Portal Identification Fo.(P3N) HL -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(If well field,one]art/king is sufficient)'
35, J 2 _�l ID 12•Certification:
G.Is(are)tlte weg(s) permanent or QlTemptirary signam)re ofCcn��d yell Contractor J CJ ��
nm
7.Is this a repair to as existing well; Dyes or 2)i 7o 3Jf Sig^tng this form,I hereby cart fy that Nte ncll(s)ryas('ora)consrntcred in acmcdnnn.fftds is a repo",fill out d'nmvu well Comintctfan infonnalion one/explain the uumre o the 'Vill,15d NC4C 01C.0100 or lid NCAC 02C.0200 Nell Canslnrcrian Standard.mid drat a
repair anda,01rumor"@ section or on the back ofthisjam,. f PT-f1his record has been pmvidadtagn. ,all aromas.
S.ro 3•Site diagram or additional well details:
r Geoprobe/DPT or Closed-hoop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction derails. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface; SUBNt1TTAL LNSTRUCTIONS
For nudriple tveHs list a0 daps/tr ldLeran Z4a. For All Rells(emmpfe-3@300and2@)o0') Submit this form within 30 days of completion of well
{�
10.Stndc water lend halos'top of casing; construction to the following:
L'{(-
lfnurer lerel is abava cnsiag,use••+•• (fL) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: 6 (in.)
24b.For Iniection 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
z a.auger,rotary,cable,direct f a na,etc.) construction to the following:
FOR WATERSUPPLY WELLS ONLY: Division of Water Resources,Underground injccbon Control Program,
1636 Mail Service Center,Ralcfgh,NC 27699-1636
13a.Yield(gpm) 16 Method of test•. air�prressure 24c.Far iihater Suooly E Infection-Wells: In addition to sending the form to
13b.Disinfection type: 9fanular Amount: ,� Q U the address(es) above, also submit one copy of this form within 30 days oP
completion of well construction to die county health department of[be count'
where constructed.
Fenn GIN-1 North Carolina Depamncnt ofEavimmoenml Queli,y-Division of Weer Resoures
Revisctl 2-22=Dlu