GW1-2021-01569_Well Construction - GW1_20210309

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ForTnternal Use Only:Well Contractor Information:
Chris Morgan
lk`ell Contractor Nome 14' 'AT ZONES
3572
BRON To DESCRIPIIo\
ft, tt•
c Well Continctor Certification Number fL ft.
Morgan Well&pump, in,;, L�.O R aA1;mc3 r mmtt case8�vclts ORyII�>tiR rn itrnbte)
Company Name
IR011 TO DiAfHETER CKNESS 1TATERLIL
+1 ft. S7 ft
6118 ' stl2i puc
2•WOII'Conslruetion Permit#• G!1 I6•INNER CASING OR TiTBiNG(eothe at closed-foo
List all applicableum-l/ewstnrcttarr•e rRO'lt TO DIANIEtER THICI(NESS
p nrtirs(i.e UIC,COMM—Yarlance efe) n 17ATLRL9L
3.Well Use(check well use): '0
ff. Agricultural
ater Supply Well: tt' ft. In.
17.SCREEN
DMunicipal/Public rRont To DIAMETER Geothermal(Hcating/Cooting Supply) oResldential Water Sup I 'sin e) t R n
storstzE ctrns at
BindUstrial/Commercial tltgt
ft.
C11Residential Water Supply(shared) rt•
h1i orlon III.GROUT.
INDII-Water supply'vVell.- FRO11 To arATERAL
o rt. EITPLACEIIENT 1iLTHOn&Ab1QUrr
Monitoring I-t bentonite poured
Injection Well: [Recovery ft.
it.
Aquifer Recharge OGmundwaterRemediation
IAquifer Storage and Recovery QlSalinity Battier 19•S /GRAVI;F PACK ifa Pliable).
Aquifer Test FRO1t TO 11wTCRTAL
�]IStormrvater Drainage ft Kai nLacr•.nrsrrr atEt•Hon
Experimental Technology ft
QlSubsidence Control ft.
Geothermal(Closed Loop) ft.
QlTracer 20.DRILI iNG LOG(attach addition nl sheets if nemss
Geothermal(Heating/Coolin -g Return) other(explain under-021 RemaTks) FRO1 TO
1 )
DESCRn'TION color.hardness,soitlrocic 1 ,emin SiZA atei�; ft. r-5 ft. V
4.Date b5/ell(s)Completed ( Well 131 n/a
j ft• 3c5 ft. Yoylh
Sri•Well location: -� ft. C
�Emes 7,;5i.,r // , ft. 6(u Ft �'o�k
.JY, n!a ,S Z.a�ft.
Focillry/Otvncr 1Vamc ft. ,( a ro-h itv.
L196 Facility iM(ifapplicable) ft g,
�G gel i1 NC s`f ft a?ts ft
Physical Addn,ss,City.and 7ip
ft. }l,
z1.RENARI{3
County
Pamet ldcndfication No.(PiN) vA V 2 U 2
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:(ifwe[I Field,one iaUlong is sufficient) i
22.certification: DWRSeCficn
,-
6.Is(are)tite WOU(s)OPermaneat or o± --
emporary Signature ofCerti/,f)�il WcU Conwactor
Dad
7-SS this a repair to an v OJ'signing this/anti.I hereby crrta that the trall(s)was(were)cansrn�eted In accordance
p Win$well: Dyes or Q'NO uilh J5A JdG9C o?C.0I00 or IS.d NCAC 03C.0216 Well C"'ere)cunsi icl ed I n curl that
Olds is a repair,fill and se ttt wa I construction tnfonnation and etplain the natnrre ofthe copy of rids record has been pravidul fo the 2C- 200
rnpairnuder:3I remark section or on the back ofthis farm
23.Site diagram or additional well details:
S.ror Geoprobe/M or Closed-poop Geothermal Wells having the some YOU maY use the back of this page to provide additional well site details or well
construction,only 1 GVtr-1 is needed. Indicate TOTAL NUlti1BER of w
drilled: ells constuction details. You may also attach additional pages if necessary.
9.TotaI trail depth bolow land surface: 2� SLt�3itTTtA-L,-11STJCTCT10NS
roe rnitlriple wells list all depths IfdLet ear(ernmpIa-3@200'aIId 3 a J00� ('') 24a.For All S�`ells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water revel belowtop of casing; (f�)Turner leret is above casing.rise + Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
ii.Borehole diameter: 6 (in.)
24b.For Injecion veils: 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 followine:
FOR WATER SUPPLY 7t`)rLI.S ON't,Ir: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yicid(gpllt) 1� Method of test: air pressure 24c.For Water Sunni-,,&Iniection tWeIls: In addition to sending the form to
13h.Disinfection 4P •e• granular the address(es) above, also submit one copy of this form within 30 days of
Amount: Fez completion of.veil construction to the county heal department of the county
where constructed.
Fonn OW-1 North Carolina Department of Environmenud Quality-Division oflVater Resources
Revised 2-22-2016