GW1-2021-04731_Well Construction - GW1_20210527

VVtu»Jll_0 T 11QT9'MTTA"19rT0N RECORD � .....,
G��l _.__ _....
For Internal Use Only:
L Well Contractor information:
Chris Morgan
1VAT
«'ell Contractor FRZONES
ctor Name FRom TO DESCRIPTION
3572 ft. ft. i
NC NVell Contractor Certification Number 8• ft.
Morgan Weft&Pump, Inc. 15.,OUTGR CASING(for multi cnsed sveits OR LnVRR C. ncable)
IROM TO DIAMETER THICKNESS tVIATERiAL
Company Name +1 R• rt. 6 i!B in
sd27 pyc
�' / /_ .16.INNEt2 CASING OR MING(eothermal closed-loo
2,Wc[!'Conslie cell n Permit#: 35 / IP r•ROM To DIAMETER THICMESS 'MATERIAL
List all applicable aril consrnrct/an perrntrs(r.e UiC,Count State,VariancQ etGj fL ft. in,
3.Well Use(checlrwell use): 11 ft. la
Water Supply Well: 17.9 CREEN
Agricultural oMunicipal/Public FROM To DIAMETER SLOTS TH[CIQ�ESS MATERiAL
Geothermal(Hcating(Cooling Supply) QlResidendal Water Supply-(single) R It. In.
pindustrial/Commercial It• ft. in.
['�IResidcntial Water Supply(shared)
,.,Or III.GROUT.
Non:r/t'ziter Supply Well: rltonT TD MATERIAL E(vtPLACE64L•NT 11ETIIOD&AMOUNT
0 fL 20 ft. bentonite poured
[]!Monitoring ORecovery
Injection Well: fL €t,
Aquifer Recharge OGroundwater Remediation ft.
Aquifer Storage and Recovery QlSalinity Barrier 19•SAND/GRAVEL PACIC tin licable).-
FROM TO ATATERTAL EAtPLACEpiENT METiiOD
Aquifer Test oStormwaterDrainage ft. ft.
Experimental Technology Q[Subsidence Control
rt, ft.
Geothermal(Closed Loop) QlTtacer 20.DRILLING LOG(attach additional sheets if necessary)
GCOthurmal(Heating/Co)ling Retvm) _: Other(explain under#21 Remarks) ffo A, TO DESCRIMON Colo,ttardacss semracL t c e-u cIc)
ft. I fr. re W-
4.Date Well(s)Completed: / 21 �-� Well Ia#n/a is s fL
owh �tr�
Sa.Well Loeatt n: s ft.
Gb n/a 55 ft. 1(o rt. 0 4 G LC
/y it"t
FaciliryOtvnerName Facility TDff(ifapplicable) 0 ft• 3
l// 1 C Oft. bw{ f�h�tL
/ d r Q C ft. f(,
Pi sical Address,Cl d Zip it fL �IPA
J
n/a 21.REMP.Rics
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v
(ifwcll field,one lottlong is sufficient) 22.Certification: �� ;( ° ^ bill!
a'� _�U. s 3 li �Il� �~r�n�t ,�e,,on
N W EAN111 se Lion
6.Is(are)the srell(s)-OPermancut or OTemporary Signature of Curti fj9d Wcll Contractor Date
7.Is this a repair to an existing v b signing this jonn,I hereby cert�,that the i eft(s)was(were)consintcted in accordance
p btshn well: Dyes or )No with ISR NCAC 02C.0100 or 15,1 AICAC 02C.0200 Well Construction Standards and that a
U'thia is a repair,fill art A7101WI wall constnrctton information and etphim the nature of the cop,ofthis record has been ptvvided to the well otimer.
repair under#31 rentarkr section or on the back oft/tis form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-I�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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also atiach additional pages if necessary.
drilled: t
l' SUBMIT FAL INS t RUC 1 IONS
9.TotaI well depth below load surface: T O (4)list all depths 24a, For All Webs: Submit this form within 30 days of completion of well
1%a•multiple wails list (ernmpte-3@30U'amd 2@I00�
� / construction to the following
10.Static water level below top of casing:_ (ft.)ljnater lorel is above casing,use +^ �'f 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: rotary above,also submit one copy of this;form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) constmetion to the following:
FOR WATER TER SUPPLY 7i'ELLS ONr Y: Division of 1,Vater Resources,Underground Injection Control Program,
1636 Nail Service Center,Raleigh,NC 27699-1636
I3a.Yield(;pot) I Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
granular the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection is PC: Amount: D completion of well construction to the county health department of the county
where constructed.
Fort G1v-1 North Carolina Department ofEnviromnental Quality-Division of',Vater Resources Revised 2-2,2-2016