GW1-2021-01312_Well Construction - GW1_20210329

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i,Neil Contractorhrrormation: ForIntetna]Use Only: ' "'^••••^•
Chris Morgan
wen Contractor Name 14.3572 FRO r9TEREONE9
Z TO nFscRlPTloa
NC Well ConlmclorCenificadon Number R R.
Morgan Weil& Pum ft. ft.
p, Inc. ts.oOTER CASmG
Company Name FROM TO or mdd-cand,taIts OR L[N8R la ncyyta
/ DIARr6TER T�ClINass
2•WelfConstruction Pe / 6 «t R' �O f[. arn7ntu,rr.
B 1I8 in. stl27 Gx alma t7nit d: t7 _ U�001 16.INNER CgSINGO PVC
PPJlcnhle wa/lconrtnrc[ianp�^� 1 nROat RT�m'G(eothermat dosed-moo
rnn tr( U1C C o,S�alc I ar/nncc wc/ TO DIARIEraR
3•O'dl Use(chaduvel{use): rt• th 7•urcluvrss ntA7ER110,
Water Supply 4Ya E ft. is
R, la.
Agricultural f'=R 17.3CREEN
Geothermal(Heating/Cooling Suppl I—iy) �i'Municipal/Public FROM a To sARt
- Industrial/Commercial Rcsidrndal Water Supply ft. in. SLOT SlzeTmarnesg nur7ERtaL
Itri orlon [�IResidcnfial Water Supply rL
PP y(shared)
Plou-1h+ater Suppiv Weil: 13-GROUT
FRObr m
h'Ionlmting a a AlATERDrL ENPLRCEa
Injection all: Recovery 20 R, rmrr hraTrlOD Amount
bentonae Poured
end
Aquifer Recharge Imo, R tr,
[Aquifer Storage 13Groundwater Rem ft.edistion ft.
g Recovery ISalini B Aquifer Tes[ armlet19.S.WD/CR PACIC ifa ltwmc)
QlStormwaterDm Minage Oar TO To
Experimental Technology ft, nuTERraL sRtrr.nerrrarrr atFrxon QlSubs{dence Control u,
- Geothermal(Closed Loop) ft
Geothermal(Heati QlTracer ft.
ng/Cooling Retpm) - Other(explain under Re arks) Mom TO
21 20.D INC LOG(artaeh
RILL addin onol mss
sbeeerUnem y 4.Date;Yell(s)Comple[ed: S ���Z� Dasl ..I Lai ft. oN mmvr,naraaess,saNmd:Ir asnia s'o¢ate)
Well M#n/a
. r —
Sa.Wdi Location: �---- w R• 3C fr.
U ft. $C; ft. �roLJn ��r
G e�ilA,7Je n/a wrrJ S Fo ra 1 ry/Owner Nomc V v it. 76
- L Facility fDp(if applimble) �7o ft. { �•t'L� K"r
Z6 S R.
PhysicalAd, Cite C�y.and ZipL fi .QYA-01 rc ft
Lam•/( ft. ft
'Quay rtie 2767q 21.REMARiC3 \..r ..... _.
Sb.Latitude and longitude in degrees/minaPmcd[denufieatioa Fo.(P[N)
builseconds or de ��R 2 9 20
(ifrvcll field anc InVlongn sufi'icicnt) decimal degrees:
SSY9
71 ,Z 22.certification:
6.Nora)tile Wail 1�, I •I W ��
(s)�IX Permanc¢t or OTemporary
S�gavN 1 Ccn fj d wall C"o ctot
'f/bi7.Is this a repair to an csis' �+ttng rv�' Dyes or JC)Nu 'I slgning rblr fomr.1 hereby mrt�drat the uul!(rJ teas wee
c is d o,121,f(!wrt kamvo ar:/I roostnrction Infunnotte,and crplain Ibe nolure oflbe rope oflbls reror 2C been 5'm'erllo the uu//Douce
•cooly under:? Copui1 ISA NCdC o2C.0/o0 or ISA NCAC 02C.o2oo We11 Conslnrc��medidaudr^'odr�°r,�ca
J mn+arkrsecllon Oran the back afdtir(art
0.For Geoprobe/D?T or Closed- 23-Site diagram or additional well details:
construction,Only I GW-1 is needed. Indicate TOTALormEd NO BERO re same You may use the back of this page to
drilled: MBER of wells construction derails. You may a so attach aartional pages if necdditional well iessaryyails or well
9.Total well depth below land surface: Z�s SU FITTAL LNSrRUCT10NS
1'ornndrip/eu•ef/s list al/Aepdrs lfdderern(era role 3@30o and 2@/opl (fr') 24n. For All Wells:
Submit this form 10.Stntic Water level below rap of casing: C7 construction to the following: within 30 days of completion of well
f Wet level is above curing.use..+•• (ft)
Division Of Water Resources,Information Processing Unit,
11.Borehole diameter. 6 1617 IVlai{Service Center,Raleigh,PIC 27699-1617
(in-)
I..Wellauger,construction method: rOtafY non24b For Injection allsr In addition to sending
(i.e.auger,romry,cable,direct push,e1cJ above,also submit one copy of this form within
the Form to the address in 24n
construction to the following: thin 30 days of completion of well
POR WATER SUPPLY RILLS O1VLy: Division of Water Resources,Underground Injection Control Program,
13a,Yidd(,pm) G Method
Mail Service Center,Raleigh,NC 27699-1636
ethod of test! au pressure
a
13b.Disinfection type: granular
the address(es)raboveSu �Ralso fsubmit One eCOPY of this fora,sw�tdtrmm 30e drays 10
of
Amount: LoO� completion of well construction to he county heath department PonnON-1 wbere constructed, ep rtment of the county
North Camlino Deportmrnt ofEavimamcnmt Quality_Division of water Rcsoutees
Revised]-i�3ule