GW1-2021-02423_Well Construction - GW1_20210527

P,LL W1fiTSTRUCTION RIECORD(QWl 1) For Internal Use Only:
1.Well Contractor Information:
ChOs Morgan 14:1VATERZONES
tVell Contractor Name FROM TO DESCRIPTION
3572
fL ft.
NC Nell Contractor Certification Number tS..QIITGIi CASIhG Nor mui&cure@ wefts ©R L mFEtL ,r. ncablo)
Morgan Welt of Pump, Inc. IRON Ta DiADiETER Talc OMS dATERIAL
Company NName +1 1- t It' 1.119 in' 1dr2l live
lr�p� 16.INNER CASING OR TUBING 1 eothermal eloseddoo
2,Well'Construcdon Permit#: fP (�J l,( "�`((�b rxont To DIAMETER THICKNESS NATetuAL
List all applicable it-ell construction pennies(i.e.UIC,County.State,Variance,ere) FL ft. in.
3.Well Use(cheelitveli use): ft. fL 1n.
Water Supply Well: 17.§cREEty =
FROM I TO I DIAMETER I SLOT SIZE THICIMSS I MATER
Agricultural OMunicipal/Public rt ft in.
�Cieothermat(HcatutglCOoling Supply) Z esidendal Water Supply'{single) ft. ft. in
Fllndustrial/Commercial DResidential Water Supply(shared) 10 GROUT
Ini ation rROnt TO MATERIAL EhIPLACEMENT III ItHOD&AMOUNT`
Non-Water Supply Well., o % 20 ft. bentonite poured
Monitoring ORecovery fL €t.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEI.PACK(f a ticablc}.
Aquifer Storage and Recovery C liSalinityBarrier FROM TO I MATERIAL I EAIPtACENIENMAIETHOD
' _ Aquifer Test OStormwater Drainage ft' ft.
E:;peritnental Technology DSubsidenee Control ft, ft.
Geothermal(Closed Loop) E]iTraeer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCOMON cola,hardness.sailhoch t c.Amin sizA ete,)
C,cothctntat(Heating/Cooling Return) Other(explain under Jr21 Remarks) ft. ft.
4.Date Wells)Completed: " � Well II)#nia ft, � ft. ru,
So.Well Location: 0 ft,
-`5Igran t I �r�v� P'70r,--S4.+ ti/a It. Ft.
Facitiry/Owner Name FacilitylD",(ifapplicable) ft. ft.
ft. ft. ; 1
Physical Address,City,and ep ft. ft.
.Ibi.366��/-76%Jog 21.1 mAlucs v
County Parccl identification No_(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvell field,one iatllong is sufficient) 22.Certification:
03� �- TS 33 N- t W
6.Is(are)the well(s)OPermanent or OTemporary signature of CcrtTEd Well Contractor Date
By signing this fora,I herebi,cert fi,that the wall(s)was(were)constructed in accarda+tee
7.Is this a repair to an existing well. DYes or r Nia with 1.5A NCAC 01C.0100 or IM NCAC 02C.0200 Well Construction Standards and that a
If this is a a epain fill out known well construction information and explain ilia nature of the copy of this record has been provided to the iced own—
repair under 1Ql rentarla section Oran the back of thI00M. 23.Site diagram or additional well details:
S.For Geo robe/DPT or Closed-Lon Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
p p
construction.,only 1 GW--(is needed. Indicate TOTAL Nt3MBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' ! SUBMITTAL INSTRUCTIONS
9.Total v ell depth below land surface: UL) 24a.For All 'Wells: Submit this form within 30 days of completion of well
Fo:•multiple wads list all depots fdiifferent(example-3@200'ond 2@1001 construction to the following:
10.Static water level below top of easing: �� (ft.) Division of Water Resources,Information Processing Unit,
If n'ater level is above casing,itse"�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: {in.) 24b.For Injection Wells: In addition to sending the form to the address in 242
rotary above,also submit one copy of this form within 30 days of completion of well
12.Nell construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of'%Vater Resources,Underground Injection Control Program,
FOR WATER SUPPLY%TLL S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test' air pressure 24c.For Water Supply&injection Wells: in addition to sending the form to
the address(es) above, also submit orie copy of this form within 30 days of
13b.1)isinfeetion t1pe: granular Amount �1' (111 completion of well construction to the county health department of the county
where constructed.
Foml GW-1 North Carolina Department ofEnvimamental Quality-Division of Water Resources Revised 2-22-2016