GW1--06097_Well Construction - GW1_20241014

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WELL CONS litUCTIO_N itl;('(.11tj)1S1W-J l 'I'ur infernal I age t-irlly 1
1.Well COntraelor Information: Ian: .
t�3 Rot 14.WAIY3t7(JfrM I
• Wcil'NT6IV:oisunmt in0st Tu Ur i nlrlin s I
II. O.
_tJ - A _ ..___ ft. h. f
NC Well d'nntradnw CMifi:otnul Nuenha 1,y.i[f(Clr i.ASrN(i(for thill!rowed teens)UR/i,YER(If eppneahl:) .
Morgan Weil&Pump,INC _g_pukl t ht4Str rut [ (lilt KHS.S9 1 M/( I'lAI. 4
- 0 rt. i
II I, (I. r IM in , s4•)' I I•p. .
. C:.RtscvNam! . Y,.__.
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-^6 7.Do.- �14 Il _16.1NNF:tI CASINO"UR TURFING.(grotbrrtnol clmed loop) -
2.\fell Construction PermilN v tl 1 FROM sir t,isMrrrra 111(5'i(8 MATcr-Iei.
iinaR plies:blrnvL/ettnnn,Crianpe'nU(iP UIC,(s:me e yi Smtotasrr,tr:.) ft. h. in I
3.Well Use(check well use): n. it. In. l , ..... . ...1
Water Supply Well: .17.SCItEEN _�. __
rR0.11 TO iiTiSi.TER-�51.ciis. r. ((TIC eNPSS 1 5f{'(Y.p(A t, 1
°Agricultural 0Municipal/Pubue tt. ft. In. f
°Geothermal(Iicaling!Cooiing Supply) Residential Water Supply(single) n- (t_._ - fn. I f I
0lndUstriaVCammercial °Residential Water Supply(shared) in.GROur -- , -__ - I
Qltrgation FROM TO MATEnIAr. __-..S I.PIAT (r. FT{TC MRODCi AHOG'R_1
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Nan-Water Supply Well: 0 (l. 20 rt. FArconee cowed
. rMonitoring °Recovery rt. n. t
Injection Well: p- n.Aquifer Recharge °Groundwater Rcmediation -------'-'
19.SAND/GRAVF.L PAC FC(if applicable) . v�
Aquifer Storage and Recovery °Salinityllarrier FROM TO MUTPRLAL MRL4CFHFMafEfR00,_____
i t
°Aquifer Test QStormnaterDrainage R. re I
. °Experimental Technology °Subsidence Control it- ft. • 1
©Geothermal(Closed Loop) °Tracer •20.DRILLING LOG(attach'additional abet tsIfnecessary) -
0 Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO oES.RIVT ON r r,bawdom sofVroc4 lips,arale whr,etc.)
• 4.Dace Well(s)Completed: 7 Z_3`e-^KYcll Wll y R n n' elf f
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5a.Well Location: p c✓ [L -.7 el (L 15 f 4 t,P
J cS M 1O KO .7 1' '3'ii a ' ei re,171-C
Fecility.'OweerNamee ,Faa� A
AV-) 1 t-
cilityDN(ifappplcable) fe ft.
q2 i Ad,. Srcr ' te`( rt. rt. 11 t. ,.,..c;,..'pi.... . �•f j 2,., )
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Physical Address,City,and Zip
rt. ft. W'T I ' 20-_4
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County � Parcel Ie1ea6Cie:sdan Na.(PIN) (,,-::,.,:._„ ,, . ,
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: f s�- ..i.Y.'r
(if well field,one Lit/long is sufficient) 22.Ceerrtjf n:
3s.57 z6( . N V D 96 2 \Y 9'. Z- W
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6.Is(are)the well(s)ElPermanent or °Temporary Si of tallied We Contactor Dote
By signing this form.I hereby cert6 that the aell(s)was(were)constructed In accordance
• 7.Is this a repair to an existing well: ©Yes or )No with ISA NCAC 02C.0100 or 15d NC4C 02C.0200 Well Coeun,ccron Standards and that a 1
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well
repair under till remark:section or on the back of MirJone. i
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site debsils or well
construction,only 1 GW-I is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTION S
9.Total well depth below land surface: O 0 ((I.) 24a.For All Wells: Submit this form'within 30 days of completion of well
For multiple weld,list all depths IIfdiferent(example-3 00'and 2@ l00') construction to the following:
10.Stadc water level below top of casing: Z't%'C7 (1t.) Division of Water Resources,Information Processing Unit,
ryi.ater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8 1
II.Borehole diameter: (In.) 24h.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotar
y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(ice.eager,lousy,cable,direct pooh,etc,) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mail Service Center,,Raleigh,NC 27699-1636
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13a.Yield(gpm) 5 Method of test:air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one(copy of this firma within 30 days of
13b.Disinfection type: 0eaatdatedchlodrto Amount: completion of well construction to the county health department of the county
where constructed.
Pone OW-t Noah Carolina Department of Environmental Quality-Division of Water Resousecs Revisal 2-22-2016