GW1-2021-01322_Well Construction - GW1_20210329

VV E IL OO1NSTRU GW-1 - ...
For Internal Use Only:
I.Well ContrdctorInfarmation:
Chris Morgan
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIFTION
3572 11:3O R. R,
NC Well Conhaetor Cenibpdon Number R• ft.
Morgan Welt a Pump, [no. 15.OUTER CASRVG for mWd•msed sreas OR ERE r neabret FROM To DLIIIETER TRIC[OVESS - blATER1AL Company Namc +1 R' R• 61/a in•
stl21
2.i pve
LtaellConstruCtinn Fermit d: l6.INNERC IN ORTUBING(eothermei dosed_loo
sf all nPPllcahle cell roralmciioa FROM TO DIAb1ETER TRICIaVaSS
Pernlrm tee UIC,Conant State f'annnce,girl fL (t aLm7ERLtL
. a
3.Well Use(check well use):
ft. it. in.
Water Supply We CREEN
Agricultural [DMunicipeupublic 17.S 17-S To DLmntelsR ss.or size Txlcrm'ess n m stA
(DOcmhennel(He'atng/COOlinS Supply)IY) QlRasidendul Water Supply(single) n• R. Hi.
IndusMal/Commercial ft• R.
QlResidential Water Supply(sharad) lO.
rigation GROUT
Non-Water Supply Well: moot TO arA7rluAL Ga1PL\C66fENr ali?tlaD&daI00bT
,•Ioniloring 0 R. m 8' bentonile
DRecovery oourad--
Injecdon Weil: fL D.
Aquifer Recharge Groundwater Remediation ft. D•
Aquifer Storage and Recovery QlSaliniry Barrier I9.SANDlGRAVt.L pnCt[ifa Iteabte
Aquifer Test Flta^r io QI ^rATERGL
S[Ommwamr Drainage ft.. F.AtPLACFA[EM1T^1F.THOD
Experimental Technology rt.
QlSubsidence Control ft.Geothermal(Closed Loop) QiTracer ft.
20.DRILLItVG LOG(attaeh addidooa!sheets liaereaSary)
Ccodlcmlal(Heating/Cooling Return) Other(explain under 21 Remarks) moor To DFSCRIerr acamc Mraaar,mmmd:a anmsim alga
4.Date Well(s)Completed; a s-a n/a f fftt-... ,r
P WeII IIT: R•Sa.Well 1 o ation: fLfU—
��ti uL /4 .! n!a Fa{m—h(rypp/Owner Namc Facility MAP(ifappli"lik) ft. ft. �C
I C�OC� MGkt ac l t r crlo ..
PM 1 A,ddlen,City and Zip ft.
L 1 �t-�'P )r . fL
q /O•Z — I Z'L'3't, 21.REMARI(S
Coamy Parcel Identification No.(PrN) H
5b.Latitude and longitude in degrees/mlauteslseconds or decimal degrees:Of%veli(Lcld,on�ejlatnong is sufficient)
•�> - 2l\ (C)o N _ 22.CaCertification:
N (/
—Oo. i
L�
6.Is(are)the nall(s)):permanent or QlTemporary Signmum afCcni led Wall Convacmr
Dam
7.I5 tbi5 a repair to as g Bp signing rbis fontlea
,I berobp certify Ihai the rapist)[vas(mere/[alirinicmd in acc a to
P existing well: Ycs Or XQNo nilh ISA A'C4C 01C.0100 or 15.f NCAC 02C-0100 Nell Caasinratiaa Stnvlmdr,end shot e
folds is a mpair.fill call knm.,"'o"consmraion infannalion and explain die numm ofih,, rope afthis recordhar been prowdedro i0e nett m,mer.
repair aader.11 mnmrls secfioa ar as the back ofrhisfonii.
3.Site diagram or additional well details:
5.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
constructioq only 1 GW-(is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: I
3�!\ SLBNDTTAL INSTRUCTIONS
9.Total well depth below land surface: (Y Fo
) 24a. r All Wells: Submit this farm within 30 days of completion of well
fro'nnihiple,yells list all dapda Idlperern(emmpfe-3@100'and 2@!00)?@
construction to the following:
10.Static Dater level blow rap of casing;_ �//� (fL)
If muter level is a6oea cnsbig,use••>'• Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (in.) 1617 Mail Service Center,Raleigh,NC 37699-1617
6
24b.For Injection Wells: In addition to sending the form to the address in 24o
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,era) construction to the followina:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
\ 1636 Mail Service Center,Raleigh,NC 27699-1636
130.Yield(apm) V Method of test. air pressure 24e rot Water 5Imuly E injection Wells: In addition to sending the farm to
I3b.Disinfection type: granular the address farm es) above, also submit one copy of this fo within 30 days of
Amount: completion Of well construction to the county health department of the counts
where constructed.
Form G W-1 North Carolina Depaamom of Envimamcnml Quality-Division ofwatcr Resowe[ Revised 2-22-2016