GW1-2021-06946_Well Construction - GW1_20210505

oy _.................
1.Well Contractori[nformation; For Internal Use Only:
Chris Morgan
Wall CommctorName 19:tVATER20NES
3572 FRom To DESC ON
R• ft.
NC lVell Contractor Certification Number IL
Morgan Well,&pUR1 R•
p, lf1C. IS- CASINQ's or multi-eased wells O1Q
Company Name rROnt TO DIAMETER P. ra ncable
+1 R. Cr THtCtavEss i1fATERIAL
N ft. fi tla in.
Z•Well'COnstructianPerntit#: i6.1NNER ' sd21 pvc
Ustall applicable u�l cvustntctianperntrtt(Fe U/ pROnt TO
CASING OR (eotheratat closed-!oo
Cortnp,State,I'arianc4 ere) fL DIA&IzrrR THICKNESS
3•Well Use(chect.mell use): ft �7r1TERiw
in.
Water Supply Well: IL ft. la
Agricultural 17.SCREEN
p�Giro[hermal(Hcaring/Cp [�Municipal/Public FROM TO DIAIttETErt olin 5u 1 R. SLOTSiZE TH[CICI\•ESS 14L+,THRIAt,
g PP Y) OResidential Water Su i • if is llndustriallCommereial PP Y(single) ft.
fn'igation Residential water supply(Shared) ft. in
Non-Water Supply well: Ill.GROUT
rRont To ,titaTsttraL
Monitoring 'r a M zo ft, thtPLACt:ntENT-, :•�HOD&AMOUN-r
Injection. [ covery bentonite poured
fL
(Aquifer Recharge if
(Aquifer Storage and oGroundwater Remediation ft. ft
S Recovery EllSalinity Barrier 19.S.�ND1
Aquifer Test trtont AVELPACIC TO if itcabte
Experimental Technol (]IStormwaterDminage ft. MATERIAL Mir, CRniENTniIiTHOD
ogy t t, ft.
Geothermal(Closed Loop) L.JiSubsidence Control
it, ft.
QlTtacer
Geothermal(Heating(COoling Return) : Other(explain under 21 Remarks) FR I To OG lattach di DESCR�pt°°ito eot If o ha m t'1
'1•r7ate bVell(s) Re
ti h• 2 Q ft. ems.soturocr;is a eria size,otai
Well li};fl/a 20 fr. e
5a.Welt Location: % fr.
)G r g ft. Z0a �• �,,,�,
OAK rt/a rr• lr+t
FacdirytO tvncr Namc it.
,,Facility IM(ifapplipble) ft.
R.
tJ 5
Phys'al Address,City.and ZipL ft. iL v
4�
r
County n a 21.REMA�{S
Parcel Identification No.(M)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �KvoJv
(if well field,one tut/long is sulHcicnt) �G Ityx`
22.Certification:
//�f
16.Is(arc)the wells) pet mmtent or 0TempOrnry signatu fCen f vim—
)r cil Contractor
7.Is this a re air to an G Dat
P exLsting well: YCS Or n No Bp sfnith 15A this jotni,I hereby certify Cleat the rr+e44 was(mere)constricted in accordance
ePar Ca a repair,t l arkr �.it tstll cronarniction Information and explain 1he,nature ojthe r P1'ojtlus re old has b n prvvidedCo e!/mrmer.r
repair under 031 ranry Fs section or on the back oj(/tisjarnt. C-�OD Aell Caastnrctian 5fandmrls and that a
23.Site
am or
8.p or Geoprobe/tJl?T or Closed-Loop Geothermal tilells having the some YOUay use the back OfOthis page onal ito provide additional well site details o
construction,Only 1 G1,V--1 is needed. Indicate TOTAL NUMBER of wells
drilled: ' construction details. You may also attach additional pages if necessary. r well
9.Total lsell depth bel0ly land surface:2� SLBM'iTa^AL 'STRUCi1pNS
ror mnttiple irells list all depths jdiperent(example-3@300 and 3@I00 j (�`') Zc}a. )~or All Myells: Submit this form within 30 days of completion of well
M Static water level below top of rasing: `] construction to the following:
ljirater level is above casing,nse'4-" (ft.)
Division of Water Resources,Information Processing Unit,11.Borehole diameter: 6 1617 Ndail Service Center,Raleigh,NC 27699-1617
(m.) 24b.Eat iniectr_on Wells: In addition rto sending the form to the address in 242
12.Well construction method: rotarY above,also submit one co of this form within 30 do
(Le.auger,rotary,cable,direct push,etcJ construction to the followi�y days of completion of well
FOR WATER SUPPLY ViT.LLS O114Ly: Division of Water Resources,Underground Injection Control Program,
l3a•Yleld(epm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test_ air pressure 24e,For Water Sun_ Dlv E iaLtion Wells: Tn addition to sending the form to
13b.Disinfection type: granular �y the addresses) above, also submit one copy of this form within 30 days of
Amount:_ 71n� completion of well construction to the-county health department of the county
Where constructed.
Form GW-t North Carolina D epartmcnt of Envitonmenud QualhY-Division of Water Resources
Revised?-22_2016