GW1-2021-03001_Well Construction - GW1_20210527

qvffi,LL CONSTRUCTION RECORD-(GW-1) or btemal Use Only
I.Well CantractorInformation:
Chris Morgan
14.IVATERZONES
lVell Contractor Name FROM TO DESMIMOIN
I q 3572 ck
NC Nell Contractor Certification Number
IS-OUTER CASING afarm Sed tivetis ORL114ERIgae clot�n
Morgan Well&Pump, Inc. FROM I To DIA
Company Name +1 it. 61/8 FCC
2,Well-Construction Permit#: J&INNER CASING OR", ING(geothermal dlosed-loonl
FROM r0 DL4MEfER THICltNESS MATERIAL
List all tipplicallie well constr7tction pennies(i.e.UIC,Conn(l..State.Variance~etc-) % ft. in.
3,Well Use(check well use):
Water Supply Well: 17.SCR
-mom I TO DULMEM SLOTSIM--1 TRtcrrnEss mriTERIAL
Agricultural DMunicipal/Public IL & to
DGiothermat(Heating/Cooling Supply) esidential Water Supply(single) :=ft, in.
I:)1ndustriallCommercial residential Water Supply(shared) M.GROUT
_11nigation Mom I To-
EMPLACENIENT air 1101)&ANIOUNT
n-Mlater Supply Well: 0 fL 20 ft. bentoWde poured
RNolonitoling E311ccovery fL ft.
Injection Well:
Aquifer Recharge
E)Groundwater Rentediation —
Aquifer Storage and Recovery E]lSaliniry Barrier 19.SANDIGRAVE L PACK ifs ticabte}.'
FRONT ITO NTATCPTAL I ENIPIACMIFNTMETHOD
Aquifer Test OStormwaterDrainage ft. ft.
:3Experlinentat Technology DSubsiderice Control ft. ft.
-3Geothermal(Closed Loop) C]ITracer 20.MMLING LOG futtach additional sheets-ffnecessary
Danhormal(fieatingtCooling Return) FlOther(explain under 021 Remarks) FROM — To D
ft.
4.Date VVell(s)Completed _11A n1a 0
Well ID#r o ft- S p ft. TfOl--A. 'V-4—
So W 11 Location: - SON n/a Ss, -70 S4_�- h-ac-A.—
mtv's WA 7ci fr. 16 5 ft. 71-,CzhrCr_
Facility/OwnerNarru; Facility 11)"(ifapplicable) ft. ft.
_J o VS 0 a 4, ft.
Physical Address,City.and Zip ft.
Gck%llto N r4e�(.J("'t 21.REVIAMCS MAY 2 1
County
Farccl Identification wo.(PIN} L ,Ainq Unit
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftyell field,one lattlang is sufficient) 22.Certification-
95 Tq490 4 1 N I& A,7j,��� z
6.Is(are)the wal](S)OPermanent or OTemporary Signature ofCartifiEd NVell Contractorrc
f
BY signing thisfornt.I hereby mr1a that the wall(s)mas(here)constructed in accordance
7.Is this a repair to an existing well. DYes or No willswillsISA N'CAC 01C.0100 or 15,1 XCAC 02C.0200 Mell Construction Standards and that a
If &a repair,fill our known well construction infannation anti explain the nature of the copy of the record has been provided to the ivell owner.
repair under'071 remark section or on the back of this 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Lotip Geothermal Wells having the some You may use the back-of this page to provide additional well site details or well
construction,only 1 GWl is needed. Indicate TOTAL NUMBER ofwalls construction details. You may also attach additional pages if necessary.
drilled: I . It .-... — SUAMTTAL LNSTRUCTIONS
9.Total ivell depth below land surface. 6 A) 24a,For All Wells Submit this form within 30 days of completion of well
Ror multiple wells list att depths if different(hraniple-3@200'and 2@1001 construction to the following-
10.Static water level below top of casing: 416 Division of Water Resources,Information Processing Uni4
Y'viviet-level is above casing,rise 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Lulection Wells: In addition to sending the form to the address in
12.Well construction method. rotary -above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct posit,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VvT-,LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpni) Method of test: air pressure 24c.For Water Sunply&iniectio Wells: In addition to sending the form to
granular I WL the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection tc�pe: Amount completion of well construction to the county health department of the county
where constructed.
8onnGW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2--;2-2016