GW1-2021-06890_Well Construction - GW1_20210505

HEC
For Internal Use Only: •....'.".
I, 1'el1 CantrnctorTnformation:
Chris Morgan
)Yell Contra elor Name I4:1i'ATF.R ZO.iVES
3572 eMOM To DESCRtrctoN
7 0 h• R.
NC IVeil Contractor Certification Number ft.
Mo an ft.
nJ Well&Pump, Inc. rs.ovTi,It CASING(for multi-cased svetls OR
Company\'ante FROitr TO DIA11iETER Z IP7£uR(Ir Ileable)
41 R, rt. T�CICNESS biATL•RIAL
2,Well'Construction Permit#: 61/8 in. sdr2i
16•INNER CASING OR TUBING(eotheimal closed-loo pvc
C/st all applicable trel/cousrnrction permits(i.e U1C,Coarnr.Slat",1'arimic�erG) FRom
TO DIAaiETER THICIONESS
3,We[l Use(checlttveil use): rL ft A1dTEttLtL
in
�IJater supply Nell: ft. M III
Agricultural 17.5t'REEN
oMunicipaL/Public FRONT TO DIAi1iSFER' SLOTStZC
Geothermal{Heating/Cooling supply) iOResidentia!Water Su 1 siu le ft. THICIQVESS AU RIAL
'
4KVndush-ial/Commercial pp y( g ) D- In.It.
[ (Residential Water Supply(shared) ft' 1D'
Irrioation III.GROUT.
lion-Vduter Supply Well: FRo,u TO
,XIATERIAL r&IPLACEntEn•T,NtILHODSAnroun7
1•tonitoring 0 R. �
Injection LVeIl: O. Recovery bentonite poured
ft. Ft,
Aquifer Recharge t--t
Aquifer Storage and Recove [](Groundwater Remediation ft. ft.
Aquifer Test
rY oSalinitp Battier IR SAN snonr ro DlGRAV M PACIC(If a licable)
.
Experimental Technology
IStortnwaterDminage ft. ft. NIATCRIAL EiltP[.!C11I 1ENT8TETHOD
Geothermal(Closed Loop) [7Isnbsidence Control
ft. it.
Ocothem)al(Heating(Cooling Rettrm QlTracer
20.DRII LING LOG(attach additional sheets 1j necessary)
/) Other(explain under�.21 Remarks) FROM ft. TO C DESCRI Oti cold,harlots soiUmcb h C�rrio s"tze air-)
'Date Wells)Completed: Y��,�Z1 R.
'— Well IDR fi/8
So-Well Location: U ft, SG Ft.F © ft, 3V Ir rC (%J/I 4 C��
bevt/6Mn/a rc
aciliry101tmcriVamc 2,Qft. it.
Faclity rD-- :
,
(ifappiicable) ft. G
Physical Address,City,and Zip v/�'q ft. ft
4- 4—��► e.� ft.W& fib 7 4 /S. ''.tRENy
Pared Identification;Vo.
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifvr If field,onefafat/long is sufficient) j 2021
qga (q 22.Certification:
6.IS(are)the sycll(s)OPerm �/1 )1 11�%1 �sezion
or
anent o T emporm•y Signre atu of Certi kd Well Contractor C('
Date
7.Is this a repair toga existing well: .i- W/sign/mg this farm,!/rernbp cert (bat Ilse swil(s)war(were)calmnicted in accordance
rcIbis is a repai,fill oat 6nou�r well rnnstnrcrion Jr fornrariar a s n/atn the twtmre ofthe r PJ'allhis�C 01C s baen provided to the 2C.miner.
re airundcrfi,'? C.0100 or 159 NCAC 03C.0200 Well Construction Standards and that a
P 1 remarkssecllon oron Ike back,£flora r m
For Geoprobe/Dl?T Or Closed-Loop Geothermal bi/eiis having 23•Site diagram or additional well details:
construction,only 1 GW-Isis needed. Indicate TOTAL NUtvlgER of yells e You may use the back of this page to provide additional well site details or well
drilled: ' construction details. you may also attach additional pages if necessary.
9.Totnl I�ell depth below land surface: L�gv 3LBil?7 a sA1.�'STRUCa iOi�Jg
Formadtlple Wells list all depthsTcl erent(ermmp/e-3n300• Io0l 24a•For All 1-Tells; Submit this form Within 30 days of completion of well
t0,Static!Pater level beloFc top of casing: 'L U construction to the following
f hater level is above casing.use"+ (ft) Division Of Water Resources,information Processing Unit,11,Borehole diameter: 6
(III.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�
24b.
12.Well construction method: rOt8f)/ z2j tnJectl lls: In addition to sending the form to the address in 24a
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 WATER SUPPLY 3_%TILLS ONLY: Division of Water Resources,Underground injection Control Program,
13a.Yield(pat) 1636 Mail Service Center,1%leigh,NC 27699-1636
i4iethod of test: air pressure
24c UQE abater SuDDIv&In►ection Yells: In addition to sending the form to
I3b.Disinfection type- granular Amount l., the address(es) above, also submit orie copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environmental Quality-Division of Nato Resources
Revised 2-2.�-?016