GW1-2021-06967_Well Construction - GW1_20210505

v�t:JULUNPIEC 1� Gil p
I.Well Contractor-WOrmation: or at Use Only ��•" 'v
Chris Morgan
11'ell Contractor Name 1' ' 14.li'ATERZpNES
FRODt TO DES low
NC tVell Contractor Certification Number e�4Y X J 2021 ft. ft
Morgan\/Nell& PumpLs_OtITERQAgMG rmultt-coseeFwet>s ORLiNER to ttcablc)
inc.1f1C .r„r ;�L%vll(C"if��ill 1ii�i� FRONT TO D41lrtETER Company Name
T t3ICKNESS i1tATERIAL
ff 6118 in.
2.Well'Construction Permit#: 26 39 ` t 16.1NNER ( l closed-too
pva
List all applicable will constnicticopernnu(cam U/C,Corrnp.State,Yarlance e�c) CASING ORTUDLAb eot6ermst cl THICKNESS Fit AT TO DIe151ETL•R THICiCNnSS A11lTERLtL
3•Well Use(Cher well use): n rr. in,
Water Supply Well: f t' R• In.
Agricult mi 17.SCREEN
DMunicipal/Public rI1OM TO DIApIETER SLOTSIZE
Geothermal(HCIItiRgICODIin Su I it M Ia TAICIt11 hL1TERIAL,
!3 pp y) 1IResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) ft ft� to
irrigation 10,GROUT.
Non•Wnter Supply well: �� FRONT To ataTERtas
0 R ENIPLACEatEPiT METHOD&AnlotN•r
tl2onitoring fl: hantanite
Injection Well: [Recovery poured
fL ft.
Aquifer Recharge QlGroundwater Remediation ft.
ft.
Aquifer Storage and Recovery QlSalinity Barrier 19.S /GRAVEL PACK ifa iicahle).Aquifer Test FRODt To 111ATERLAL
OStormtvaterDrainage ft Fnsrt acr•.msr.-ratETHon
Experimental Technology ft
QISDbsidence Control
Geothermal(Closed Loop) Q ft
ft.
lTtacer 20.DI2ILLIP(G LOG(attach additional sheets Irnecess
Ccothcmlal fHeating/Cooling Retttm) � Other(explain under#21 Remarks) �O1f 1
TO DESCRn"I'ION color hardacss salUtaclt it a etata sizq etc 1
ft.
4.Date Wells)Completed: Well 1IT"fl/8 f
• �Q ft.
5 .Well Location:
BOO n• ft.
n/a ft. ft.
Facility/OtvncrNamc J Facilityi w(ifapplieable) ft.
tt.
ft. it
hysical Ad ss,City.and Zip J
ft. ft
n/a 21.REnrARICS
County
Parcel Identification vo.(pW
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient)
�7'53�5 IV 22•Certification:
6.Is(aro)the wells .k Pe
() ruaancnt or13 emporary Signature ofCcrtrfjt d WcU Contractor `?
7.Is this a repair to an existing hell; Dyes
By signing this/na.I her¢bp cerri/y that the riali(s)rsys(mere)constnrcred in accordance
ljthis is a repair,fill art knot»h w¢U cconstnrction nfonnation and 0 n'Itlr 15"NG1C 02C.0100 or 15,1 NCAC 02C.0200 Nell Conrtnrction Stmtdantr and that a
repair under 421 remarks section or on the bark-of tbisfornt erpoi»fire nathhre of the rep)'afthis record has been provided to the'rrtll owner.
23.
e diagram or
S.I:or Ceoprobe/D-PT or Closed-Loop Geothermal Wells having the same YOU itmay use the back ofthi additional a eltae s
construction,only I GW-1 is needed. Indicate TOTAL.NUMBER t esa p g provide additional well site details or well
drilled: to details. You may also attach additional pages if necessary.
9.TotaI ivell depth below land surface: 5b�� Sl,�MITTAL�S UC:ipiyg
Ibr"triple wells list all depths IfdLer ern rerample-3@200•and 200000aaaaa1001 (`) 24n.For All %Veils: Submit this form within 30 days of completion of well
to
10.Static water level belocv top of casing:._ (-�
construction the following:
If irrtter lei al is above cvsing,ase•'+•' (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (in.)
1617 Mail Service Center,Raleigh,l'1C 27699-1617
246.Far IDiecfion 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY VvT-,LLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(;pm) Method of test. air pressure 14c.For Water SuDDIv IniecHon Wells: In addition to sending the Fatm to
13b.Disinfection type: granular the address(es) above, also submit doe copy;of this form within 30 days of
Amount. OZ- completion of well construction to the county health department of the county
where constructed.
Font aw-1 North Carolina Department of Environmental Quality-Division of water Resources
Revised 2-w 3016
I