GW1-2021-00612_Well Construction - GW1_20210205

L y i"Ailu�..Ulm a 1111'U4:11'10N RECORD L -IJ For inertial Use Only:
I.Well Contractor Information:
Chris Morgan 14.W4TERZONES
Well Contractor Name
FRODt To DEscRiMON
3572.
ft, ft.
NC Weil Contractor Certification Number I i,,r,.00TR CASING fror TWI-_ca-d wear ORLWER rapI[cabtc
Morgan Well sac Pump, Inc. = opt TO DMlt1IETER THICIN.ESS biAlERIAL
+1 li, J ft. 61B in. sd21 live
Company Name 16.INNER CASING ORTURING(eothermal closed4onol
Z,Well'Construction Permit#. f 1 r•Roat To DIA61 P. THICKNE5s I '&UTERIAI,
List till applicable well cwratnuction permits(i.e-UIC,Cottag:State.Variance err") iL ft in.
3.Well Use(check well use):
Water Supply Well: I 17.SCREEN
Agricultural rRoal TO DIAMETER SLOTSiZE THICIMM hLtTE tAL
QRMunicipaUPublic fc IL In.
Gcotherrnal(HoutinglCooling Supply) IRResfdential Water Supply'(singlc) ft.
Industrial/Commercial OiResidentiai Water Supply(shared) 10,GROf1T..
fni anon rR0162 I TO 'NATER41Ir I EhiPLACE61ENT aiETHOD&AntOUA'C
!`ion-Water Supply Well: o fL ft. bentanite poured
Ilylonitoring ORecovery ft, ft.
Injection Well: 1t. fr_
Aquifer Recharge DGroundwater Remediation
19.S /GI2AYEL PACK if a lieabie'
CiAquifer Storage and Recovery QlSalinity Barrier FRONT To MATERIAL snrrLa Gra�t6NT�1ET4ioo
Aquifer Test �lstormwaterDramoge ft. ft.
Experimental Technology QlSubsidence Control
Geothermal(Closed Loop) OTracar 20.DRMLINGLOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other( lain under„21 Remarks) FRO`'r TO DESCRIrst N coto. rdness,sotttrotIt: r.2mlos'rca ctc,i
p d ft. �� fr. � l
4.ante Well(s)Completed[ �� Well EIDp O/a -30 4. 1 !o`::> ft. . 1rz4 d(r�-
So.Well Location: 6-' it' $0 ayt(i
c5 z., De'&CCp .f% n/a ft. / 5- it. btbw-r� lC
Faciliiry/}OwnerNama ; Facility M".(ifoplpliwble) l` fG. 2_(0ft. !20_4L�11
l"�t'1��1( '�'.,l CAAU<AA RA " N't'r�� t etc 2'(0'c&3 ft. ft
,' ft.
Ysical Address,City,and Zip - ft.
JI&N0 h n!a 21.RE-MARISS
County Parcel Identification No-(PIN)
5b.Latitude and Longitude in degrees/mlauteslseconds or decimal degrees:
(ifwall field,one lat/iong is sufficient) 22.Certification:
3S.S26o - sue ` W t l
f
it signature of Ccrti&Well Contractor Date
6.Is(are)the tyell(s)OPermartent or D;emporary Ti
By signing this fans.I hereby rertfy that ilia walls)irw(Ware)constntcted In accordance
7.is this a repair to an existing well. Dyes or n)No uitlr 15A NCAC 02C.0100 or 15A NCAC 02C.0300 Well Construction Standards-und that a
If thfs is a repast;fill out bim+hiu well construction infonnotion and explain the nature of Nha cop}-ofthis record has been provided to ilia imll oavrar.
repair under 1:21 rantarkr section or on die back of tbisforur
23.Site diagram or additional well details:
S.For Ceoprobe/BDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL.NUM t,! 4 I1 /�tntction details. You may also attach additional pages if necessary.
drilled: ' �/ ittl3!i AI,1I+ISTRUC110PIS
9.Total w depth de th below land surface: ( 4a.For All Wells: Submit this form within 30 days of completion of well
rorauthiple uvllsltst all depths 6rdWmin(ernnrpie-3(a7300'and 2t3a 10 Construction to the following. y p
10.Shine imter level below top of easing: L� t "•_ -;Qf4Q t 2rnr.Ming Unit Division of Water Resources,Information Processing Unit,
if artier feral is abut=e rasing,eso 't ' DWR Section 1617 Mi ail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ro, CID.) 24b.For Injection lValis: In addition to sending the form to the address in 24a
r01$r}l above,also submit one copy of this form within 30 days of completion of well
12.Well Construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,cicJ ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(,pin g } Method of test, air pressure 24c.For Water Sunni-&Injection Mielis; In addition to sending the form to
.
C� the address(es) above, also submit`one copy of this Form within 30 days of
i3b.Disinfectiongpe: granular Amount: 1 8 z completion of .vell construction io the county health department of the county
where constructed.
Farm OW-1 North Carolina Department orEnvimnmental Quality-Division ortliater Resoures Revised 2 22-2o16
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