GW1-2021-01309_Well Construction - GW1_20210329

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REOOItD GW-1
i.Well Contractorhd'Drmatlon: For Internal Use Only:
Chris Morgan
well Contractor Name K.IVA ZONES
3572 FROaI to UZZI PTION
NC NNI ConDamor Cul(6rnrion Number O
� R.
Morgan Weil& Pump, Inc. Is.o t1T'ER CASING or mdLUIET yens OR Company Nance EOM TO D41AfEfER LMER a peablo)
^� +t R. R TRtC[WF9S - mnTERIAf.
2•Wdf Construction Pe `(f� L trV•iINNERst/a 1p' sera
Llst nfl rmit#: JDC.. FRONT
CAO GORTURING p�
apPlfcahfe urflmurrtrcdon pennfrr/i.e U/C,Garotte Smre,Yarrrsnce,neJ fROm TO f eot6ermal dosed-la°
DIAN Ell TH/CKNEss 3,Well Use(checlt well use): ft• R. Ira oteTEluu.
1r✓atnr Supply Well: ft. R• lo.
Agricultural II-
SCREEN -
Geothermal(Heming/Coolin� OMunicipal/public FRONT TO IAatEraR
e Supply) !t R. SLOT Sig
�lndusMallCommercial ldential Water Supply(single) In. THICIa1'ESS °LITERL
QlResidentiaater Supply ft. ft.
!ni anon l W PP Y(shared)Non-Water
rin Supplyla.GROUT
well: FRONT TO MonitoringafA
0 R. lEl¢,u• EMPL%Ce&JzW mL?II¢D&AMOWT
Injection We]: C�IRecovery ZD It• bantonae poured
Aquifer Recharge fL ft.
❑IAquifer Storage DGmuod R
water Remediation ft. .
g and Recovery Salini B 19.&WD/GRp Aquifer Tes[ ry alner YEL PAC[C tfa Itwbta)
DStonawa[er Drainage AtOar TO 61ATERTaL
Experimental Technology R•sidence Control ft
Q1Tra enmucmtsn-r ueTeon
Geothermal(Closed Loop) 1lTracer ff fit.
Cmthcm)al(Heati nglCooliog Retum '-0,DRlLL G LOU(attach additto Isheets IP necessary)
' Other(explain under—'21 Remarks) FRONT To
aESCRIPTIO\ eola.had°esr,solamchh ¢rslo the elel
C.Date�YeII(s)Completed: d ft. 15 R.
^�', Well 1D#n—� O P
5a.Wcli Location: ft.� 3ta ft.
II �� ` O ft ft.
.r
i t W Igr•cl n/a 1S ft• Car
Facihry/Owner Namc � fL R. ��
Facility rD-(,Fappl,.ble) fr. r.aC
ww R. �
Phy I Address ` O ft. ft,C,ty and Zip
4i7C6(A Q (� ft. R:
Caunw �-- A� f� d` 21.REhIgRK3
t'atcel Identification No.(PIN)
Sb•Latitude and longitude in degrees/miautes/seconds or III O.(PINdegrees:
01 well Ffield,one IoUlong is sufficient) I 1 .
�lf, ....� I sI s � 22.Certification: L. „
m ,lb W 6.Is(are)tile¢cU(s) [perm a¢c¢t or QlTemporary C�/J,
�1vs g om
C.rO
7.Is this a repair to as rL--1t' Bf rfgning rbis for„p!hereb Dale
Mpai it a repair,fill ma k„o,ne�s�g a�ruian(r f nnaliof aperplain rbr nonrre ofrOc mp7 154 A rAC 02 -been pruvlded rAC ruefl 200 V�f'are/constructed unni in accaMm,ce
u'ir6 IS.I A'GIC 0?C.0100 or/Sd NCAC OIC.0100 Well Canrtroe/ian 9areda,dr and d,or o
repair m iler��/remarkr secrlon ar m,the back ofdrlrfomt.
g._r.or GeoprDbe/DPT or Closed-hoop Geothermal We7Is bevi,g It, some 'Site diagramhe back o additional
pageltoe1ro s:
coaslruclioll•only I Gttti is needed. Indicate TOTAL NUMBER of wells You May
drilled: 1 construction details. You may also attach additional pages if nvide additional leclessar)te �. or well
9.Total well depth below land surface: SL-BNIITTA L INSTRUCTIONS
for nmOlp/e uxlls lfrr all deprly ldperem(eromple-3@200•and?@100] (ft) 24a. Fat All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: constructiom to the following:
Inater fcrel is alnn,, siag,use"+•' UL) Division of Water Resources,Information Processing Unit
11.Borehole diameter: 6 (In) 1617'Vail Service Center,Raleigh,NC 27699-1617
24b.Fat injection Wells: In addition to sending the form to the address in 34a
t. Well construction recthad: .) above,also submit one copy of this forte within 30 do
(i.e.auger,rotary,cable,direct push,em.7 construction to the following: days of completion of well
FOR WATER SUPPLY W LS ONLY: Division of Water Pesources,Underground Injection Control Program
(gPm) ,
13a,field / Method at tesr. air pressure 1636 Pail Service Center,Raleigh,NC 27699-1636
'24c For Water Sun aly E Inigetio Wells:
13b.Disinfection kvpe: granular _w Ne address(es) above, also submit one copy of this form sending
30e days to
of
Amount: (j completion of well cons action to he comfy health department within
of the county
where constructed.
Farm G19-1
Nodb Carolina Dcpanmmas efEnvhonaccnul Qualoy-Dlvi =ofwater Resources
Revised 2-2r1-2016