GW1-2021-01305_Well Construction - GW1_20210329

vvE�x UMASTRUCTION CORD OW_l I.
For Internal Use Only:
1.Syell CantractarYtlformatian:
Chris Morgan
Well Contractor Name 14.ti'ATERZONES
3572
Otl'4 R. TO DESCRIPTION
R,
NC Well Contractor Cenifieadon Number ft.
Morgan Well d:Pump, Inc, is.OOTER cA51IVG(rormWti-mz¢d nclls ORLWER Iry Ikabta
FROG[ TO Dfk1lE"CER T®C[4YFS5 MATERIAL
C'raany Nanta +1 ft. IL 61/6 in.
qq {/ to stl21 pvc
21 4ye11 COn5trUCHOn Permit": 2J yWo .MVER CASING OR NniNG(eothermalelosed-Ioo -
List all goplfcalaewell........troy aennar FROM TO DW5 MR THICICNESS MATERWL
(t.a U/C,Cotunc Stare.f'arirtnce,era) iL ft.. in.
3.Well Use(checliwall use): ft, ft. lo.
tiVater Supply WeD: 17.SCREEN
Agricultural [DMunioipal/Public FROM TO nIAMaT n sr.OTSIZE THIcIMSS nL1
(—DT.Gcothermm Heating(Coollnn ft R. I .
4-1 ( Supply) [�lResidenlial Water Supply(single)
�I Lndusttiai/Commercial Ql ft• ft. irL
Residential Water Supply(shored)
Irriafltion ID.GROUT
r"Plon-tauter Supply Well: CRO01 Tn arATettuL cstrLAcentsn-r afmt°D�nmounT
QlMonitoring 0 ft. 20 ft' henlonile pnurea
?fljcction Well: DRccovcry ft ft
Aquifer Recharge DGroundtvater Remediafion ft. R.
"lAquifer Storage and Recovery ElISaliniry Barrier 19.SAND/CRAVELPACtCpia lirabld
Aquifer Test FRO11 To hiwTERWL EniPLACEIf EnT 01F.THDD
DStonnwaterDminaee ft, ft.
Experimental Technology QlSubsidence Control
ftT14M_ch
ft.
Geothermal(Closed Loop) ft.
(attach additiaaal sheets lrr,Ccothcmtal(HealinglCooling Retum) Other(exlai d 2DEECRIITI calv,D. `Datc iVell(s)Completed• S�Z� , n/a• Fell ➢� fL YC)So.Well L°eation: '�ft. o6 rer•res n/a rt. ��G�n � Facility lD9(ifapplicable) ft.
/77 14 VbtCSkonG Yf bkr�dsa„ � it. ft.
Phy.aai Addmss,City,and Zip ft. it.
e 171e g6Gy 89 S Z87 '-1.DEntARtiS
County Parcel Idendficmion No.(Pitt
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: v
(if,yell field,one lot/iong is sufficient)
3S Sia 7 z L 22.Ce if caHDa:
� AY
G.Is(fire) '/ �rIs(fire)the waR(s) X Permanent or D7emporary S,gnmu v m( cru Well Contractor -- Dam
7.Is dtis a repair to an existing well: 83 rlgaing this Juno.(hemb3+cerroy 11m1 dre uxd/(s)uus lu.uel comu.,cred in accordnace
Yes or 2)I'Lo nilh 15d NC.4C 02C.0100 or 15d NC1C 0_>C.0200 IYell Canstmcui a Srnuda-de and rhal a
repai ix a ur 1*1 fill out knmvn tval/coastmclion infonnanan can eiplan,the retort,oforie cape ojr6fs rccordhnr been pruviderl to the neli uuaer.
repair urrdrr mil remark section or an the back ofthit(am:.
23.Site diagram or additional well details:
G.For Geoprobel9PT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional cages if necessary.
drilled: '
Sli3h ITTAL LnISTRUCa'IOIS
9.Toini well depth below land surface: (�J (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
"a"anddpie trails tint oil depdv ffutyereur(eran,ple-3@?00"anQ 3 100`)
/V construction to the following:
10.Static water later helms rap of casing: (£t.)
lfuster let Of n abam ]Division of Water Resources,information Processing Unit,
coring,arc"+"
1617 Yfaii Service Center,Raleigh,PIC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For iniection Wells: In addition to sending Ole form to the address in 24a
12.Well construction method: rotary above, also submit one copy of this fo= within 30 days of completion of well
(i.e aVCef,rotary,cable,direct ptrsh,Ctc.1 construction to the followino_:
FOR ATER SUPPLY TN Division of Water Resources,Underground injection Control Program,
TNT. DPZY' 1636 Mail Service Center,Raleigh,INC 27699-106
138.Yield(gpnt)�_ 'Method of test. air pressure 14c­TOr "tartar SuD°iv E iniech011 51'ells: In addition to sending the foam to
/� ddressesm within 30 days of
tab.Disinfection type: anular me a
gr Amount: 0� completion(of) above, also submit one copy of this forwell construction to the county health deparvneth of the cotinty
where constructed.
FDm1 GW-1 Nonh Carolina Department ofEavirovmemei Quality-Di.rivion ofwemr Resour cs • Reviscd 2-23-2016