GW1-2021-00603_Well Construction - GW1_20210205

LrVu.1, ON RECORD GW-1
For Intetaal Use lhtly: - - -
1.Well Contractorbribr mtfon:
Chris Morgan
Well Connector Name 14.WATERZONES
MAI TO D6t:RIptIDN
3572 o fL m
NC Well Contractor Certification Number R. ft.
Morgan Well d: PurnP, Inc. MOUTERCAS G or mWn-eased+mlis OR LINER C FROM TO DraAIETER wma
Company ♦1 ft Name .H[cau E46 - ASATERIAL
• tt• 6 V6 in.
+� stlQi an
2.WCIfConairuCtiaR permit#: Zo�� ,7& 'KUfil ER CASING 0R2IJ61NG( eothermal closed-loo List gill usetllllecij well use):
se: perMttt h,e U/C,Conn(r,State.Variance,eIC) aROM1t DfAAIEfER Hie Ess ADITRRLiL
R R In.3.Well Use(checltrveli use):
Water Su f R' to.
Pral 17.SCRgEry -
o"Othatural DMunicipaVPublic most To sLOT sizE
t7eomermal(HrnrinpfCoolin Supply) R tt. la. Tnrenr� nta
QIndg aResidential Water Supply(single)
Tort atrjallCommemial DResidential Water Supply(shared) ft R• In.
Tort anon 1R GROUT.
Non-Water Supply Well: FROM TO A7aTERLv. EMPLACEMEM'nt ROD&Amourrr
Monitoring ° 2 m R. eemonae poured
njeetian Well: Recovery R
tt.
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery QlSaliniry Barrier 19-SAND/GRAVRf,pAClC if a Itw6IN'
Aquifer Test FRDnr TO Afa7ERGL
QlStormwaWr Drainage R En7pLACFxt6xr nlaTRoo
Experimental Technology R'
QlSubsidence Control tt ft.- GeotheMR (Closed Loop) CIT"m
Geothermal(Healin Crolin Return 2a•DRILf.➢vG tAG(oaach a He on I sheet:6necesary>
Other(ex lain under f:21 Remarks) EOM To DEscR, oN eulan hmdatas,aalamchn z. In size ate)
J R,
4.Dam 6ye11(s)Completed: ] nla •`^
Well iDk ft.
M So.Wel/ Sft.ell Location: ro(,lsGy �,�I J v� n/a VIC
''
R.
Famltry/ rmcr NAmc Facility ff Y•(ifoppiiwblc) ft. R.
Physical Addres,Cnl,and 7Jp
tt. tt.
Age, �d�� 21.REMARICS
County parcel[dcadfio Uum No.(p"
Sb.Latitude and longitude in degrees/minutes/seconds or dec[mai degrees:
(if well field,one lottlong is sufficient)
`1 S r N sw N 22.Certification:
6.Nara)tile wa➢(s) permgaLm[ or QlTemporory SgwramofCcntt wanContradm Date
7,!s[Ills a repair to an existing well: Dyes or X[INia Bp signing rhir one"1 hereby"Hify Ihat the mell(s)was(mere)cowril d in actor dance
!f Ihls is a repair,fill otn two"'wdl coanna:r/an Infonuadmr and crplafn the mums oftho rwPT ofdds rca ordhos bean pruvidrdio de wit o,00 Nell Coavtnarioo Srmtdetdv aa./d nr u
mpnir under 021—arks section or on Itre back ofilarfarin.
23.Site diagram or additional well details:
S,For GeaprobefDPT 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. YOU may also attach additional pages if necessary.
drilled: '
9.Total rrell depth below land surface: V 3+ it TTAL INSTRUCTIONS
Pormnhfple nulls listaildepdtr lfddera,u(ammp/e-3@300'and2@10 ) 24a. For All Wells: Submit this farm Within 30 days of completion of well
L/0 �j 2apa`
10.Static water level below rap of easing: uttor on to the following:
(f F E� �(lL) U�L
inter level it a6m-a cwah(g,rnv••+•• Owylsion of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
y,jOn Processtn9 1617 Mail Service Center,Raleigh,NC 27699-16I7
• OR SB"ZAb.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method; rotary above,also submit are copy of this form within 30 days of completion of well
(i.e.auger,many,cable,direct peak etc) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 14BB Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: air pressure 24c.For Water Sootily @ Injection Wells: In addition to sending the form to
the address
(es)granular Amount. b� (es) above, also submit one copy of this form within 30 days of
completion of wall construction to We county health department of the county
where coashucted.
Form Gw•t Nodh Casofiaa Dgpaasawt oFEoviroamcnul Quality-Division of water Resources
Revised 3-21$0I6