GW1-2021-03022_Well Construction - GW1_20210527

VVLLJL Q: I�T9TRUC�TIOI�I tC�D�{{'aW-1) For InternalUse Only:
1.Well ContrractorWormation:
Chris Morgan 14.WATER ZONE5 r
ltuell Contractor Name FROM T4 DFSCtIIPTIOY
ft. %i ft. j
ft. ft»
NC tVell Contractor Certification Number CpgM or multi-cased tivells ORILiNER tr, ncttbie
Morgan Well&Pump, Inc. FROM To DMIETER THICfIN&4s MATERIAL
Company Name �Akl C U j S-Z,
+1 ft. rt. 6118 in. sd27 pvc
I l 16.INNER CASING OR'i'i18rAIG(eotGexmal ciosod-loo
2,Well Construction Permit _ (, r•ROM I To I nfAMETER ITHICIcrtEss a1ATERIAI
List all appllcahle Well construction pervnils(4ce U1C.County:State.Variance-etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17-SCREEN
rRom To DIAalEM I SLOTSUt THICIMTss a tTERIAL
Agricultural DMunicipa!/Public fc ft. in
DGeathettnat(Heating/Cooling Supply) oResidential Water Supply'(single) ft ft. in.
(DIndustriailCommercial DResidential Water Supply(shared) 10 GROUT
Initiation r•ROM To MAURtAL rMPLACEM]IN ATErson&Aalourrr
Noll-Wilier Supply Well: 0 rL 20 ft. bentonhe poured
- Monitoring ORecovery ft. ft.
6J1
jection Well:
ft. ft.
Aquifer Recharge oGroundwater Remediadon
n
(Aquifer Storage and Recovery ISalini Barrier 19.SAND/GRAVME PACK ifa licable)'
ry FROar To I arATERtAL FAIPLACFa1E#TMETROD
Aquifer Test DStormwaterDminage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed loop) C]ITracer 20.DRILLING LOG(attach additionatsheets if necessary)
Ocothormal(HeatingiCooling Return) : Other(explain under 021 Remarks) FROM To oESCRIV171iON color;hardness,saittrudt type.erain 47A otal
O ft. ft. 4
4.Date Well(s)Completed: t 2 1 1 Well IDn n!a ft. I Dr
fk.
�p Sa.Well Location: ft. S'
/\('Y� S�F~' Er(,hQJ n1a 116 ft. �f(
Faciliry/OSvnerNamJc,� / Facility IDry(ifapplicabte) t 3 ft. 4 J.d. 4 ;yt,.
Physical Address,City,and Zip / ft. ft.
G,,.t✓�(,,.. Okk. to I()G S 21.REMARIGS P
County Parcel Identification ilo.(PIN)
Sb.Latitude and longitude in degrees/miautes/seconds or decimal degrees:
(iftvell field,one ladlong is sufficient) q a; ryp� a i l li
3 Lly�7� !. l3 22.Certifca71;
rl); �v11t : .G4, S.n�� if)— �=` �u .��� mat I Z 2O2N
Nero) ()O- OTemporury Signature ofCerti 6d Well Contractor Date
b,Is are lire tiyell s.•X Permanent or
3),signing this fom:,t hereby cerrify that the unll(s)wtrs(were)constructed in accordance
7.Is this a repair to an existing well: DYes or n No uilh ISA Nr_4C 02C.0100 or 15 i NCAC 02C.0200 Well Construction Standards and that a
If this is a rapair,fill out known tvell consintetion infonnatlon and explain ilia nature of the copy of this record leas been provided is ilia well owner.
repair under t21 rawarIx section or on the back of thisform. 23.Site diagram or additional well details:
S.For Geogrobe/DDT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW i is needed. Indicate TOTAL NUM13ER of wells construction details. You may also attach additional pages if necessary.
drilled:_' Lt I SbBMI TAL P4STRUCTIONS
9.TotaI well depth below land surface: �� (ft-) 24a.For All 'Wells: Submit this farm within 36 days of completion of well
Far multiple wells list all deptlhs ifdijj'erenr(crumple-3@200"and/2@1001 construction to the following:
10.Static water level below top of rasing: Lrl 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: {in.) 24b.For Infection A-Veils: In addition to sending the form to the address in 24a
t3.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 push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR.WATER SUPPLY%T_,LLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-11636
i
r 1t 13a,Yield(gent) Ysetltod oStest:
air pressure 24c.For Water Supply&iniection�Wells: In addition to sending the form to
V
tt �y the address(es) above, also submit bne copy of this form within 30 days of
13b.Disinfection type: granular Amount: i 1 d completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resotaces Revised 2-2-1-20I6