GW1-2021-06891_Well Construction - GW1_20210505

'-Well For Intemal Use Only:
contractor><ttfotmadoD:
Chris Morgan
11rell Contmctor Nome 14.lir9TER ZONES
3572 FnOAI TO DESCRIPT101
Ct.
NC)Yell Contractor Certification Number R
Morgan W It
9 Well a pump, Inc. Is.OUTEtt CASING For multi-cased tvcIIs OR LINER r,
Company Nante IROM TO DIAttIETER lteabro)
+t R, T�CI4YESS MATERIAL
Q ft. sue in.
2,th/el!'ConstTuctinn Permit#; l t �C�� t6,llyNEg sd21 pvc
List all appllcah/e t"e!lronstnrction penniu(i e UlC,Cotrrut.State,1'annnc�ere) CASING ORTU6IdIG(eothermoi closed-loo
FROIt TO DIAMETER
THICICNESS IiATERLiL 3.Well Use(checlt well use): ft. is
gAgricultural
ater Supply Well: ft' ft. In.
17.SCREEN
[pMunicipal/Public FROM TO DIAnIETER sLOT LME
Geothermal(Hcating/COolrng Supply) i�"IR�idential Water 5u i 'sin le � Ft' In. '�s nt,1TERtnt,
hhtdustriallCommercial - pp y( g ) ft.
DResidential Water ft• in.
flrigatioin
Pon^deuppy Well: ]II.GIp
i 1 .
TO
diATE[UAL[�A4onitoring o ft.ft. � E6IPLACEMEAT,IIETHOD&AMOUR?
Injection Weil: []'Recovery bentontte poured
Ft.
Aquifer Recharge
oGroundwaterRemediation ft. ft
Aquifer Storage and Recovery QlSalinity Barrier
19.S
Aquifer Test AND/GRIL pACIC(ifa ncable)
_
IStormwaterDrainage FRonr To fit. MATERIAL FUNIPLAer'NI NrMETHOD
Experimental Technology it•
Geothermal(Closed Loop) QlSubsidence Control
ft, it.
[]]Tracer 30.DRILLING LOG(attach additional sheets i necessary)
POrotharrnal(Heating/Cooling Return) � Other(explain under;:21 Remarks]
FRWI TO DESCRIPTIO celo.hartlaess so30rocl:! c�rrio size et�1 4.Dare Well(s)Completed: 'b-?, G fit. 1.5
--� Well IID..`n/a
5a.Well Location: ' fir•
✓b4►w �G
- 6 i�O�_ O ft. 3CG n'
�@ V2]or e•„fir]/a IC ft.
Factlity/OivncrNamc Oft• // �
Facility iD#(ifapplipble) fit. In ✓�y+T'G�
�-E It+/Y '�oo ! fir.
Physi 1 Address Ctry and Zip �C 1 �tw t1h tt' ft
it. ft y. a
County /V ?,, 21.t'CE ARIC5
Parcel Identification,lo_(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvell field,one lat/long is sullicient) ! l
/l ' ��?nrt3rryri� Lj��iii.
'177 CSo� Z2.Cei•tification: ur:v� a1.�
6.IS(are)the syell(s)OPerntanent or T
QI_emporary Sigstaturo of Ccltifji<ii Wcll ConUactor
7.is this a repair to an existingwell. Date
DYes or ):I4o aJ sfb'tting t/iis jornr,I lrerebJ>cerl tlrat the ur1/(s)ryas(,,'ere)constnrcted in accordance
jlhlc is a repel",fill aril knotyri well constnrct10n infonaati0»and eiplafn ilie nutare ofthe repJ ojr/i/sr_4C 0 C.01 DO or 15A S provided(o C 02C.D20,�e ell ConslntGiun Standards and dint a
"epair mtder ?l"encode.section or on the back ojlllis jornt
5,For Geoprobe/DDT or'Closed-Loop 23•Site diagram,or additional well details:Moog Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
constmction,only 1 G4��I is needed. Indicate TOTAL NUMBER of wells
drilled:! construction details. You may also attach additional pages if necessary.
9.TotaI ri•ell depth below land surface: �O( d RN SLB `IA FFgSs'RUCTIONS
1 a tmrkiplc trolls list all
deprhs fdLere)"N-ratnpie-3@200 and 2@1001 (`) 24a. For All �3reDs: Submit this form within 30 days Of completion of well
10.Static water level belo1v top of easing: construction to the following:
/water level is abovecnsing,its, •+^ (ft.) Division of Water Resources,Information Processing Unit,
11,Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rO' rY 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 6€`ATER§U1'PI.Y Vt`I;
t LLS ONr y: Division of Water Resources,Center Underground Injection Control Program,
13n.Yield(,,,rpm) air pressure , b iialeiQ
hp NC 27699-1636
i4lethod of test: p 1636 Mail Service2ac.For Water SunDly�T
2 niection Wells: In addition to sending the form to
Fab.Disinfectiont}pe: granular �� the addresses) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the count
where constructed. _y
FOnn ow-1 North Carolina Department of Environmental y_Qualit Division oFlVa[cr ����
Revised.:...;_016