GW1-2021-01335_Well Construction - GW1_20210329

For Internal Use Only:
1•Well ContractorInformation:
Chris Morgan
Well Contractor Nome F WATER ZONES
ROai TO ➢FSCRIPr1OR
3572 rL R.
NC Nell Contractor Certification Number fL R'
Morgan Well R Pump, Inc. OUT RC mat: or mWHeared vurrul on ac(if_npp11 ill
[ROnt TO DlAblir ER TEICKNFSS bfATER1AL
Company Name +1 ft, it. Gila 1°• sdm pile
2.Well Construction Permit.#: �-� 5 16.INNER CASING ORTURING(eothermaI closed-too -
FROat TO DIA67LTC0. THICICNESs r1117ER41L
Lis!of7 applicable uref.cour.nrc.iaa permnr o.a.U1C Cnan(r.sale.VaHronca rra) ft. ft, in.
3.Well Use(check well use): ft. R in
Water Supply Well: 17.SCREEN - -
PttOn[ To
GCothelmtal Municipal/Public f. R DIMIET In SLOTSIZE THICIOTM bLITERLII
Oeo[hcitl/C(mmorg/Cooling Supply) Residential Water Supply-(single)
' IndustriallComme[cial rt•
QlResidential Water Supply(shared) Is.GROUT.
Itriaation ni
Non-Wu[er Supply mo
Well: TO niATFar r. ENPLACUIEHT ML'rnoD¢Anrou,T
h a R. 20 R. bentonite poured
eriooting []IRecmcry
L(jection 1hre11: R• ft.
Aquifer Recharge QlGmundwater Remediation R' R'
QlAquifer Storage and Recovery QlSalinity Barrier 19.SANDIGRAVEL PACK fa liceblell
Aquifer Test ISI FRONT TO niATER[AL PA1PWCel tElPr ntETNOD
Q ormwa[erDminage R. R.
Experimental Technology DSubsidence Control
ft. ft.
Geothermal(Closed Loop) QlTrncer 20.DRILLING LOG(attach additional shee6lfneeessaq)
Omthcmmal(Heating/Cooling Retom) . Other( lain mile-121 Remarks Oil TO DFscRiITloN coin,hnNac 011 ad
a o C.aratn,
q ) Et. ;v {p irG em7
4.Date Wells)Completed:�- Z Well ID#n/a n ft. �- sr.
_ n
5a Well Location: J Er. �. g, {.
Icdiry/Owne-Numc Facility ID'(ifapplicable) S ft. �p ft. L
ft. ft.
physical Address,City.and Zip it. ft.
A)'Ayl nla 21.REMARI(S
County Pamcl Idcmill ationNo.(PM) _
5b.Latitude and longitude in degreeslmiuutualseconds or decimal degrees: '` H
(ifwcll field,one 120003 is sufficient) 22.Certification:
3IS r _.
6.Is(am)ttte wells) IX Permanent or Orferaporary Stg,umm ofec 7"Well contractor Dal
3J'signing rids form.I herobp cvrth,ilia,Ilia unit(s)uns(uwm/constructed in accordmree
7.Is this a repair man existing well: dyes or QNo n'ilb 15:1 NCdC 01C.0100 ar 15:1 A'C!C 03C.02a0 hell Conarmtimu Smndor/s mu!that a
repair
is a under'
fall and hmoun n or rorthe back
fnfonnoriw and atPlain the nunrre oftba toPJ'ofdris recardhar been prvvidu•1la Jac nv:Il mrwar.
repair wrder:_2l remorkr section or on d¢8aee ofrbisfomr_
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may rise the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwclls construction details. You may also attach additional pages if necessary.
drilled: '
�J SL-BNTTAL INSTRUCTIONS
9.Total wall depth below land surface: /` (f) 24a. For All Wells: Submit this form Within 30 days of completion of well
pnrvrudfiple wells list all dep,lu ffdLerenr(eromple-3@300'and 2 tr 10P)
construction to the following:
P
10.Static water level below rap of easing: 3)U (ft.) Division of Water Resources,Information Processing Unit,
6rumrer tare(is obmm calf"g,rise'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: G (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ralary 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 push,eteJ -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mall Service Center,Raleigh,NC 276994636
130.Yield(gam) 'e_ Ytethod of test. air pressure 24c.For Water Suoolv E Injection Wells: In addition to sending the form to
lar the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection ripe: granu Amount: yD,E, completion of well construction to the county health department of the county
where constructed.
Fonn GN-1 North Carolina Depmmcnt of Environmental Quality-Division of XXrwu Rccources Rcviecd 2-21-2016