GW1-2021-00636_Well Construction - GW1_20210205

✓u,CONSTRUCTION RECOIL GW"1)
-
r, ForIntema)Use )l
.Well Contractorinformation:
Chris Morgan
'yell COmraemr Name 14.IVATERZONES -
3572 FILOhl R. TO nFscRlFrloN
R.
NC well Contractor Cenif.ehe Number IT. R,
Morgan wait a Pump, Inc. M0 RCASING armdd-eosad nags ORyWRR ,r Ileablc)
FRONT TO DWtefER
Cumpzny Name +1 R. 6 THICtOrFSs - MATERIAL
I •0 ft. 61/B in.
2.WelI'Covstructinn Permit#: W o -079.5.1 i6-INNER CASING ORTUa[NG salt me
4rt all appllcnhle uv!/eonrtmcllon pmnitr".c U/C,Cmmp,S}atG f'arlanc4 etc) �1 TO (thermal at -too
DIAMETER TIT RNPS$ ay\-���
3,Well Use(check well use): R' 1p•
WaRr Supply Weg: fL !L In.
Agricultural 17-SCREEN
MuniclpaVPublic FRONT TO DEAai
Oirorhomral(Hootin [t xLor6tZE rnrctm7ss M1NTE V.L
g/CDoung Supply) idrntial Water Su ( 'sin a R- In
Industrial/Commercial PP y( � ) ft,
[]IResidential Water supply R' In.
hti ¢lion 18.GROUT.
Non-Water Supply Well: FRO14 TO mA,tfilwL
Monitoring D ft. EM1ipL\CEM1mNr METHOD&AmOONT
QlReeovery ZD R' beMawe
Infection al: It. pause¢
R,
Aquifer Recharge [�G- roundvlate em ft.Rediation n
Aquifer Storage and Recovery QlSalinity Barrier 19.SaIVD/GRA.VELPA IC if reabte)
Aquifer Tcst mom Ql StotmlvamrDminage R TO coin[-•vcwwExraterxoD
Experimental TenhnDlogy R• MATERIAL
Geothermal(Clog Loop) QlSltbsidence Control
QlTmcer
Geothermal CooliD R 2m0a tDR1LLfNG LOG(attach additional sheets RnDass
I ) El Other under.21 Remarks) To DESCmrrtOY rotor,banlpc a,sclomch tl ea mzuc cent 4.Date Wells)Completed: 1 Z� f� Well[Dq O/a ft- d R'
eJ U
So.Well Location: �— R' d R.
, IQ f k n R.
'9f•!r) 2.S' ale 2 6S R. �
Famliry/Otmcr Namc 'jyt
�� Fac1rylDa(ifapplia6le) R. ,5"
d R.
d I zhi of nL�fIUC/ R. R Phys 1 Address Clry and rp
R• ft.
County
21.REMARit3
Pascal Idmuficatioa No.(PIN)
Sb.Latitude and longitude(if is degrees/minutes/seconds or decimal degrees:
well field,oac ladloag¢sulficicnt)
3s S I l 9 N t N e 4 / 22•Certification:
1 1 W
6.Is(are)the W'en(s))r Permancut or ITem o I 'r 02 l
0 P racy s[;not sc ofCrnt z d\Nall Coamich,
7.Is this a repair to an existingwen: Date
1:-1, 3Vs(gning tills am.I hereby earth that lite uall(s)was(mesa)Mo,'ctrd in aceordan a
!flhts isarupalr fill ran Anoov well cvnnnrction halbrinarian and explain ilia nature oflha 'rapt'aflhlsr4C 01 .010 0,15,1 Cerlole2el.0200 Well Conslmevion loedardr and drata
repair under e21 ramar/s rerllort ar on l ha God oflhisfpmr.
S.for Geoprobe/DPT or Closed- 23.Site diagram or additional well details:
conSlruCti Loop kale TOTAL
Wells MERhay. the same You may use the back of this page to provide additional well site details or well
on,only 1 GW-ll)s needed. Indicate TOTAL NUM$ERR of wells construction details. You may also attach additional pages if necessary.
drilled: � 1 t
9.Total Wall depth below load surface: G ? SL TTAL nVSTRUCTtONS
parvnu/ap/e wilt'list'it depr/H fdlparem(asomple-2(uj200'and 2@100yC 14
V or All '*Veils, Submit this faint within 30 days of completion of well
30.Static water level below rap of casing. i,.L`` conswction tD the foilmving:
(f timer level is alun cos6rg,sae"+" G 10 Division of Water Resources,information Processing Unit,
11.Borehole diameter: sm9
6 r t VI\t)1617 iV[ail Service Center,Raleigh,NC 27699-1617
`p t�IO6_g,Is,rFor Ioie,�yplls; In addition to sending the form to the address in 24s
t2.Well construction method: rotary gVk S vc,also submit one copy of this fa wh
ole ithin 30 days
(i.c.auger.rotary,cable,direct push era.) consWc[ion m Inc following: of completion of well
FOR WATER SUPTZL It WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Ufan Service Center,Raleigh,NC 2 7 69 9-1 63 6
13a.Yield(,rye)_�_Nethod of test• air pressure
24a For Water Sunoly E IniecN Wells: In addition to sending the form to
13b.Disinfection hype: granular the address(es) above, also submit one copy of this form within 30 days of
Amount U 7 completion of well construction to the county health department of she county
where constructed.
Poet Gnu-I
Noah Carolina Dcpann,cm ofEmimnmcnlal Qasusy-Division orwater Regi mes
Revised 2-2-1_2016