GW1-2021-06951_Well Construction - GW1_20210505

L Well ContractorYttfotmation: For Internal Use Onl y•
Chris Morgan
Well Contractor Name 14.iV4TERZONES
3572 rRObi TO DESCRlPTIOiv
tt. (t,
NC Nell Contractor Certification Number, % R• j
Morgan Weil&Dump oUTetz anaitvG iror m01-cased woos OR-f V— (tra iTcablc
!nc• FROM T
DIAt1IETER TWCEQJESg btATL•RrnL
Company Name +1 ft. Et. in.
/- 6116 sd21 cave
2.Well'CDnstruction Permit#:_l lr/� 16.INNER CAS NG ORTURING(Bathe- Al closed-Ion
List all app((cah(e trencoasmhction peromts(t,e(/!C,Count;State.itariance,etc.) FROM ft. TO DTAatETER THICICNE6S
11ATEIiIAi,
3.Well Use(checliweli use): ft to.
ft. ft,Water Supply Well: 17.SCREEN
Agricultural DMunicipal/Public moat To DtAn1ErER; sLo'rSUN
Geothermal(Heating/CoolingPP1Y) ®1Residt:ntial Water Sus
Su R T1tiCttl�ESS h i RML
1 ' m a Tn.
Industrial/Commercial pp y( e ) fr.ft.
DResidential Water Supply ft. to
fmgntion 10.GROUT.
Non-Ir"Mr 3uppiy weli! r•Ront To a1aTEMI.
0 fL Eh1PLACEMENT11 TfiOD ANOun7
[�IA4oniroring 20 bantonite poured
Injection Well: [ Recovery ft. ft.
Aquifer Recharge Groundwater Remediation % ft.
Aquifer Storage and Recovery QISallnity Barber 19.SAND/GRAyEh PACIC if n ticable).
Aquifer Test �-+�� FROM To NATERiAL
�..I'StormwaterDrninage ft. TO
F-niPLACF.niSNTniETHOD
Experimental Technology 01Snbsidence Control
Geothermal(Closed Loop) EL ft.
QlTiacer 20.Darr r ErtG LOG(attach add i6oauf sheets tf recess
Owthcmal(Heating/Co0ling Return) Other(explain under 21 Rematics) Off TO DES1 Onal Y color,hardness solUrodt i c.`Fora arzG etc)
t7 ft. �5 Et.
4.Date Well(s)Completed:4449—Well Im n/8
is ft. 4O ft YVUH d1Y�r So.Well Location: ft.
475 `t. 6lrowh Yoe.
n/a 5 ft. oft. blur i(Facility/Owner Namc
Facility iDR(ifapplicable) ft.
ft.
Physical Address,C1ry,and Zip
ei L S n/a 21.RENARItS
County �'--'-'
Paiwl Identification No.(PIN) ` j111
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tifwcll field,one laVlong is sufficient) C
lei, `�5 (� N 6 AS O O 22.Ce�rficationn:�ti
— D W `+ �e�
6.Is(ara)tile crell(s)OPermanent or TQI_Cmporary Stgnatu fwell Contactor Dole
7.Is this a repair to an existing well: Dyes or n No t6dtbsgni g 111iC o3C 0100 or 1 certify
N I,,,l_if a IsU 00)FIt 6vere)Colutrrcons umom Fin and dance
re pai is a er#21,fii(ma known will corhstnhction injonnation and arplain the nature ofhbe roP1'ojt/ds recordGar been protiderJ to tGc ue(1 mvhter.
repair outer#21 ranharkr section or on ilia back ojdhisjorm.
23.Site diagram or additional well details:
For Geoprobe/DFT or Closed 3,oDp Geothermal Wells having the some You May use the back of this page to provide additional well site details or well
construction,only 1 G4i!1 is needed. Indicate TOTAL NUMBER of wells constriction details. You may also attach additional pages if necessary.
drilled:
9.Total iseil depth below]and surface: SUBii/PtT1?s.�'STRUC3IONS
Poh•'it ltiple trel(s list all depths(Jdderehrt(erampIa-3@200•and 2 a 100J M") 24a.For All VIeils, Submit this form within 30 days of completion of well
J consuuetion to the following:
lj
10.Static stater level below top of casing: S O
nuter level is above casing,age •+, Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For_Iniection VVeIls: In addition to sending the form to the address in 240
t2.1Ve11 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 following:
FOR WATER SUPPLY WELLS ONLY: Division o€iVater Resources,Underground injection Control Program,
1636 Mall Service Center,Raleigh,INC 27699-1636
13a.Yield�'Pm) 195 Method of test. air pressure 24c,For Water Sunalc E infection Wells: In addition to sending the form to
I3b.Disinfection type.. granular the addresses) above, also submit joae copy of this form within 30 days of
Amount: �02 . completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvironmental Quality-Division of water Resources
Revised 2--21--2016