GW1-2021-01334_Well Construction - GW1_20210329

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u digs ILK--J : ION RECORD (GW 11 ForIntetnalUse Only: _ _. _ .._
1.Well Contractorinformation:
Chris Morgan 14.WATERZONES
Well Contractor Nome lltOni I TO I DESCRIPTION
3572 IT. n
NC well C(Kaamlor Certification Number n• R.
Morgan Well 6[ Pump, Inc. �OouTRTec Jeln r r.awof TOo E�leER THICEGIESw O S n ttlmxGRinL
Company Nome +1 u. ft. 6118 in. salt pvc
16.INNER CASING ORTUR[NG(eothermal closed-lint 2,Well ConStructinn Permit S• 33749-/ FROM TO 111,010KR THICIMESS NTATERlnt.
List all aealicalde nvilc,-Im liaa permar(,.e UIC,Caunlr.Stale.Far(ance,eta) ft. R. in.
3.Well Use(check well use): ft. ft. Ia.
Water Supply Well: 17.SCREEN -
Agricultural [3MunicipaV FRONT TO Public DIMIEI'ER SLOTSIZE 7HiCIQi-E55 AT ITERLll.
n
Gborhormat(Heming/Cooling Supply) ®IResidrndal Water Supply(single) IL In.
Industrial/Comme[cial ft• R. In.
QlResidenfial Water Supply(shared)Imati IS.GROUT.
aon
FRONT TO MATERIAL E6IPLACa6tENT NIUIIGD&Ahloahl
sMon•Wu[er Supply Well: D ft. R•
1•fonitoring benlonire poured
[�Recovcry ft Itilcetion Well: ft.
]Aquifer Recharge OGroundwater Remediation ft. R•
QlAquifer Storage and Recovery QlSelinity Barrier 19.SANDIGRAVEL PACIC fa limbial
Fh11•LaCP.nlElvi htarnoo Aquifer Test QlStormwaterDm FRONT TO inage ft. [[, nrATERGL
Experimental Technology DISubsidence Control ft. O.
Geothermal(Closed Loop) MITmcer 2o.DRILLING LOG(attach iddiglshoM lF neeess -)
Goothcmlal(Heating/C°oling Return) Other explain under r721 Remand) FRDa1 TO DEsrmr11noa cmaq imrdaYss.v,dvmdrt asmm stu,em>
4.Dam Well(s)Completed: G t-� i�I Well 1Dk nla
So.
Well L
in
eation: ' I ' fr. n� k. �r,`,•Jh rc i�
f�V tCTLNl: VcYlrf n(a R21.RZVAA=RU1(0S
Facility/Owner Name Faacility[DR
(ifopplinble),J l( Nl �rJi«qical Address,City,and Zip n/a Coumy [dcmificadonNo.(PIN)5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwdl field,one lat/lon;is sufficient) 22.Certification:
351 014z Pi
W �
6.Islam)the n'Cll(S)n PermaaeOt or QII'empDrary Signamrc ofcenw/�fjhd NVcit Contrdcmr Dale
Bp slgnin;rldr form,!herebp rnnh•r/rat(he wrc7!(s)wvat(vereJ consm¢ted in accm•dunm
7.Is this a repair to an esistiag well: Dyes or XQNo nidt 15A NC4C OZC.OJOB or ISA to O-C A2aa Nell Coaermcria,Smndm•ds and drat o
ffthis is a repair•,fill and Zrtann mail wasimctian fafama ion and arplain rile Nmure aliha roPJ'ofihir recordlras been pruvidul to the dull mwmer.
repair under;:21 remadssecliort orar ehe bacAofihis form
23.Site diagram or additional well details:
S.For Geoprobe/DPI-or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
cormauction,only 1 GRr-1 is needed. Indicate TOTAL NUMBER ofwclls construction details. You may also attach additional pages if necessary.
drilled: '
SURNUTTP1.Pi 1STRUCTIONS
9.Total well depth below land surface:
l:ar•n (fw) 24a. For All lVel[s: Submit this form within 30 days of completion of well
urltlple weeps list all
depdu tfdLereni le- 2Lnl10a� construction to the following:
10.Shfic water level below rap of casing: (ft.) Division of Water Resources,Information Processing Unit,
(rnuler larel In ob.,,.cvsMS,usa"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For 7nieedon Wells: In addition to sending the form to the address in 24n
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
construction to the followina:
(i.e.auger,rotary,cable,direct pasty etc.) -
DMsion of Water Resources,Underground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Pail Service Center,72elefgh,NC 27699-1636
13a.Yield(,pm) 3 Method of test: air pressure 24e.For Water Suooly&injection Wells: In addition to sending the f°ml to
lar the address(es) above, also submit one copy of this form within 30 days of
tab.Disinfection tipe: granu Amount: �(v�7. completion of well construction to the county health department of the county
where conslnicted.
Fonn G W-1 North Carolina Department of Environmental Quality-Division orwater Rrmoures Revised 2-22-2016