GW1-2021-00608_Well Construction - GW1_20210205

For Internal Use Only: .
L Well Contrnctorlaformatlon:
Chris Morgan
Well Contractor Name M WATERZONES
mom 71 DFSL'RIPfION
3572
NC Well Convector Certifipdon Numbtt ft.-
ft.
Morgan Weil &PORIp, Inc, tS.ODTER CASING ormWti-rased nrIls OR LWnR eabto) -
1120M1I 70 DIAM1IETER r&C[4YEGg - brATEmpL
CumponY Nome "1 R. 0 ft• eve in. sd2l
-1 16.WNER CASING ORTI1aING( eothwit At closed-loo
2,W"IlCocahle I /)c PetT...w, OO U 1g� FROM TO DIAMETER THICIWESS MATERIAL
List off appltrnhle cell mn.frtrcr(on permry h•a U/C,CmmU:Effie Yarlonce,as iL
1 R. in.
3.Well Use(check well use):
R. la.
FAgricultumi
ply Weil: 17.SCREEN
rontasterER saorstzE
MunicipaL/Public OM1 MATERIAL
al 01ea11aglCooling Supply) ph Residential Water Su I sin leCoHe":Vl (LAP Supply
g ) fit• fit. in.
_ Residential Water Supply(shared) 1R GROUT.
Ini ation
Non-Water Supply Well: FROM TO aLf7PRGl rAIPLACEMENr atEi'110n s AATCIU r
Monitoring �RCCOYCry a ft. 2a R bettbtnea poured
Injection ell: ft. rt.
Aquifer Recharge DGroundwater Remedietion
[Aqu
er Storage and Recovery QlSaliniyBarrier 19.SAND/GRAVEL PgCK f Ir
er Tes[ FROar ATERLIL
QlStotmwaterDrainage tL Rimental Technology DSabsidence Controlermal(Closed Loop) ITracer rt additional sheets if ne
ermal(Heatin Cooling Return) Other explain under821 Remarlrs) Moat TO DESCRIPTION=ton h-Manw.wy.ck 1111114= nsbq era
f� t 4.Date'Well(s)'Well(s) �I1(s)Completed; `\-�'1 Well LD#nla 0 G - r C
2 0 n. QCOLIn
5a.Well Location:
S 3(jft. ZrJR' f4�(G� C 4M'
N � nla rt. R•
FaalirylOtmttNamc� I I 'Dr
iDR(ifappliablc) R. tL
Dr C�q, 64, rl fL
Physical Addre�ssi,(City,and Zip �t p f4 ft
_mi l iedden�c+rftl.- aillip' ����Q(�t�—VO -1L REMARIfS
County '7-- Panel Identification No.(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifsvell field,am Inthang is sufficient)
22.Certification:
2`I"1760 n _-- &�.�5�6 W I� - gyp' , S ( 1/
6.Is(are)the well(s) Permanent ur DTempotary Sigmtum ofCcniryCvd Ncll C ao met" Dtu���`
7.Is this a repair to an existing well: Dyes or )No ir1d 15A NC4C 02C.0100e01 I5.4f CACr02C.0]00)Well Con Inrc a,S m dare.o f�lmrro
lflhis v o repair,fill ran knmar wof!waSm,rpon lnfonnation and explain the nature alrha roPJ'afdiis meordhat been provided to Ne uall miser.repair under e71 ranrarls seellon aron the hark offhis fomr. .
4�E Ulte diagram or additional well details:
G.Far Geoprobe/DPT or Closed-Loop GeoUlerma!Wells a may use the back of this page to provide additional well site details or well
Cori fuCfi0 ,only I GW I is needed. Indicate TOTAL NU o svc s construction details. You may also attach additional pages if necessary.
drilled: ' 1
22 0 FE(b X 5 202�SUBh'llTTAL INSTRUCTIONS
9.Toml wall depth below land surface:- (ft). 24 r All Wells: Submit this form within 30 days of completion of well
For nndrlpla axl/s list all depr(u{/'dderem(eramp(e-3@30a'andl@I110�;On Processm��y1 --
tion to the following:
10.Stntle rater level below rap of casing:- '7 U DWR Ser`.'/f1On
/fnnter Pere!tr above casing,me"+^ "") Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,RnlNgh,NC 27699-1617
IS.Borehole diameter 6 (in.) 2db.For iaiection Wells: In addition to sending the form to the address in 24s
12.Well construction method: rotary - 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 WELLS ONLY: Dtvision of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(rym) ` Method of test: air pressure 24c.For Water Suonit•&Infection Wells: In addition to seeding the farm to
granular Q The addresses) above, also submit one copy of this form within 30 days of
tab.Disinfectionape: Amount: 11 D L completion of well construction to the county health department of the county
where constructed.
Fowl OW-1 North Carolina Dap...,ofEnvho conamel Qmfily-Division orwater Resa uen Revised 2-21-20I6