GW1-2021-00598_Well Construction - GW1_20210205

WELL C®1QTgTPYTC-'irrsRT vs�.�®� (CqU 3)
For Internal Use Only: _ _. . . .
I.Well Contractor information:
Chris Morgan
Ndl CammCtar Name lA 1YATIItZONES
FRO"I TO DFSCRIPI'l0\
3572 17 a !7 R.
NC well Contractor Certification Nombv rt. It.
Moryen Well Q: PUnlp, Inc. fs.OUTER CASING for multi-cased wells ORLWER r cable
IRON TO DIAMETER TinC[OfFSS - IIATERIAI
Company Name ^`I Q +1 R• ft. 811a '"• stl27
J l U�` I&INNER CASING ORTU@ING(eothermal chased-too p�
2.We1PConstructinn Permit d: r•Rwt
Ust all applicable uallcvnrfrrrclionp (', TO DfAbtETER TrICiCNGSa NA7FttL1L
emitr r a WC,Camgr•star,Parronce,wy tL R. is
3.Well Use(cheep well use):
Water Supply Wcg: 17.SC M -
Agricultural QMunicipaUPublic mtosr TD nrAntETEa SLOTSUE TiffC[QiES3 MATERIAL
IAL
Oeotheranal(Hmtmg/Coolin Supply) n• R. lo.
g 1 ],,R idenriai Water Supply'(singlc)
Industrial/Commercial R• R fa
QlResidential Water Supply(shared)- h7i ation 13.GROUT
Non-Water Supply Well: FROM MA7aRLiL EbmLdceatEra nhLmfoneAnlourcr
lExperimental
onitoring a n m n wntwme
�Reconry poured
ction WeIL• n R•
quifer Recharge [Groundwater Remediation ft•quifer Storage and Recovery QlSalinily Barrier 19-SafATER1ALquifrr Tcs[ QlStormwaterDrainage n Ft.Technology QlSubsidence control
othermal(Closed Loop) ITmczr ttach additional sheets II necessary)
2dcrmal eatingfCOoling Return) Oil" [xPlain under 2l Remarks) PRrsf TO DESCRI o\ emea no aae zrmv-eau J e
0 t4 �R• ala see eca)
4.Date Well(s)Completed: '•2•v 'Z• Well Mo n/a
2 9v R /rvo , n;l t
So.Well Lacati n: O R• � R• r�tY � �✓.L f
'(1,��k6�r J /�l rp-n vn�G nla R. n 4
Faciliryfowacr Namc Facility Me Ctfspplicable) n R•
1-12 £l+/Siq,n- b . MOOrcSV"(Je n n
Phys 1 Addnss,City. nu Zip n n --
al fe ,1gg6 L/6 176Y 2LREMA n —_
County Parcel ldrntifimtion No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if well field.am lot/long is SUM,*,)
5-e 5 a 76 G 2 pU 22.Certifeatio/n�: -
�
6.Is(arothawall(s)OPcrmanent sgnnturcofCtmtf NcOcootmcmr ���-' ZO ZGZ•(
or �Tempornry r Datc
7.Is this a repair to an existing well: Dyes or XQNo 8iib signing INS 0 C 1 he ar ' NCAC d'-t n2 0)I1 Con rnrcno„Standards in
ac d."cc
ffibls IS a-pair,fill out kno,nr 1-11 cortsrn¢am information and cphun Ibe nmure offha ropy'15A A r4C 02 - 100bum provided ro the Zell o 00 P'
repair urder:21-marl r swibm or on dm back ofrbisfam.
\fAmite diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells be ' 1 v ay use the back of this page to provide additional wall site details or well
coaSIRICHon,Only 1 OW-1 is needed. Indicate TOTAL M)MB� cansmrction details. You may also attach additional pages if necessary.
drilled:., 11
18 S F E� x
9.Total null depth below lead surface: 1Q NDTTAI,rA'STRUCTIONS00"4.7�n j�
Ibrraulffple bells fist all deplfu ffdderenr(erample-3@20a'and2@1007 (>t) 111 Wells: Subunit this form within 30 days of completion of well
PfO��t
10.Static hater level below top of casing: ..nWD ��structioa to the following:L/G if,mter lord is above caring rue••+^ Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
1617 W leigh,lail Service Center,Rol NC 27699-1617
(in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pmh%eRJ construction to the following:
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 h?aU Service Center,Raleigh,NC 2 7 69 9-1 63 6
13a.Yield(gpm) Method oftesc air pressure 29e For Water Supply E injection Wells: In addition to sending the form to
136.Disinfection hP e• granular m d.L the address(es) above, also submit one copy of this form within 30 days of
• Aount: completion of well construction to the county health department of the county
mbere consuueled.
ro m GN-1 North Carolim Depanmeat 01120y onmenui Quality_Division of water Resources �a
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