GW1-2021-06976_Well Construction - GW1_20210505

For Internal Use only.-
I.Well Contractorinformation:
Chris Morgan
ttrefl Contractor Name 14•1i'ATERZONES " " � .
3572 e�+ rRonl ro aFscRleTion
E- � `
NC Neil Contractor Certification Number R• ft.
Morgan Well& Pump, inc. X i- 2021 Is.our>;Rcwsirvo ormnlotcgsedlvcrrs OR
hROA1 TO DIAMETER LINER fn en IQ
Company Name +1 ft. TMCUNt;ss ainTERtAi
Q�Ift vii� a'sLt31 C�Jir ��3 fG 6118 in.
2.Well'Construction Permit#: _/ tG.rRNER sd2i pvc
�17�ut!� EC�'Ofl CASING OP MBWG(cattle rnral elosed-loa
---
List all app!lcahle""I/canstnre110"Pe-&r(r.e.UIC.Coanrr.Stole.Variance etp) FROht TO DIAMETER
� THICIwi:sS 11ATERLIL
3.Well Use(check well use): ft• in
�IJater Supply Well: ft. ft fa
17.SCREEN
Agricultural alMunicipal/i'ublic rRoni To DLOJETER
t3eathermat meatinglCoolin $u I SLOTSiZE THtCIQ�ESS 98 IAL
8 P y) IiResidential Water Su 1 'sin le In
-- Industrial/Commercial pp y( g ) fr.
[ IResidential Water Supply(shared) ft. ,n
flrigation 10.GROUT
Lyon-Water Supply Well: FRont To diATERGtL
D it. AM IN'Monitoring tt bentonite
Injection Well: Recovery poured
ft. R,
Aquifer Recharge Groundwater Remediation R'
ft;
' Aquifer Storage and Recovery O Salinity Barrier r9•SANDIGRAVEL PACK if a ticable.AGuiferTest FROhi 70 ATAT£RtAi
OStormwater Dminage ft. £ir1PLACn11f£NT atFTHOD
Fatperimental Technology
QISubsidence Control ft.Geothermal(Closed Loop) £t.
QlTracer 20.DRILLitvG LOG(attach additional sheets if nerrss
Gcotitcmlal(fieating/Cooling Return) Other(explain under,21 Remarks) FRoat
TO DESCRI I ti color,hardness sol!lroclt i 0.etaio sires etch
4.Date Well(s)Completed Well II};T n/8: 3 a ft. �s it. t
�$ D• sa it.
Sa Well l.oc tian: SQ
• ft.
nla rr. ft.
i acil iry/Otvncr Namc Facility III(ifopplicablc) v
t (( £r. ��ft. {�t
tri �� �vc�► N G 28/�7 ft. r
rPical Address,City,and Zipft. ft.
n/aounty
Panel Idcndfication No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwcil field,one lotilong is sufficient)
�S•��nQ _-go, 5)7 Q 22.Certification:oCJ �� r-
6.Is(are)the wel](s)�ermaaent or (]ITemporary /Signaturc o£Ccrttf d Wcil Contractor Doti
7.Is this a repair to an existili well. Dyes or E)No Bp slI , this j tree,I hembp certify that flee xt!!(s)leas(even)contrnrcred in accordance
Ijlhis is a rnpair,fill ant drtattilr torn rnnstnrctlon Infonmttan and Ct7tlaln the narnre ojthe roPP ojth record hasb�en pro0 Or �ideilCdC 01C;Q20n0 ifteJl Conrinrclion Standards and that a
repair under g21 remark"secilon or on the back ofthisjotm to ilia
23 Site
onal Well details:
S.For Geoprobe/D PT or Closed-Loop Geothermal Wells havingthe some ay use the bac dofttthis page to provide additional well site details or well
UMBER of wells
construction,only I GW 1 is needed. Indicate TOTAL N You m
drilled: r construction details. You may also attach additional pages if necessary.
9.Total well depth belowland surface: 24.tJ SUB&ZITt AL INS-
1%orundriplewellslistalldepthsY'dorerern(example-3Q200•and 201001 (�) 24n• For All Wells* Submit this form within 30 days of completion of well
t construction to the following.
0.Static heater level below top of casing:_ C
ljrtllter level is aboveemstag,are••+•• `� (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
1617 Mail Service Center,Raleigh,NIC 27699-1617
(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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,etc.) construction to the following•
FOR WATER SUPPLY RT.LLS ON_r y- Division of Water Resources,underground Injection Control program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.`field(;pm) Method of test: air pressure 24c For Water SunaIv IniectioRi
the address `Wells: In addition to sending the form to
13b.Disinfection type- granular (es) above, also submit one copy,of this form within 30 days of
Amount-. completion of Weil construction to the county health department of the county
where constructed.
Form OW-1 North Carolina D eparmrtm of Environmental Quality-Division of Water Resources
I
Revised 2-2-1-2016