GW1-2021-06831_Well Construction - GW1_20210419

=1&LU-NITRUCTION RECORD( For internal Use Only:
I.Well ContractorInforination:
Chris Morgan 14.WATER ZONES
NVell Contractor Name FROM I 'TO I DESCRIFTION
3572 9,;'% -
NC Vell Contractor Certification Number
to.IOUTE,It CAMG(For ad Welbbl IMMR(if nnntfanbld)
Morgan Well&Pump, Inc. FADIAMETER
I THICIOMS MATERML
Company Name r +1 6118 in. sd2l I pvc
16.INNER CASING ORTURING fireoth at closed-loonj
2.Well,Construction Permit#: FRONT TO I DIAMETER I THi-r­­JCN-J-r_q-q----J al.A-mPlA
List Oil OPPlIcahle Well cansintclion pmajtr(i.r-UIC,Cotogn State,variance,etc) fL ft. ia.
3.Well Use(Checkwell use): ft. ft. la.
Water Supply'VVQU: L17.SCREEN
FROM J To DIAMETER SLOTSIZE THIcimEss I 1vtLj.,TER1A
Agricultural DMunicipal/Public IL EL to
DGaothermat(1-1cathigiCooling Supply) residential Water Supply-(single) ft. ft.
r— in
industrial/Commercial DResidential Water Supply(shared) =
nhgar 18.GROUT.
on MOM TO MATERIAL E Fi HIOD&AMOUNM
te v Well:r Supply
Nott-Water Supply Well: 0 fL 20 ft. bentonite poured
n
Monitoring ORecovery ft. ft.
Monitoring
W 11.
Injection Well:
AfL ft.
quifer Recharge DGmundwater Remediation
__ r_�V EL
Q 19-SAPIGR
Aquifer storage and Recovery E]ISalinity Barrier -FRONT I To
Aquifer Test oStormwaterDminage ft. ft.
Experimental Technology (2lSubsidence Control
Geothemal(Closed Loop)
DiTracer 20.DRMLING LOG(attach additional sheets If necessary)
I
Geothermal ffleatingtCoOlit)92ELu�m) lOther(explain under-021 Remarks) TO
4.Date Well(s)Completed: well ID"M n/a
6$�
5a.Well Location: 15
n1a,
Facility ID#(ifapplicable) ft.
Physical Address,City.and Zip ft. ft.
/_;,?ca Via Z q:;7!g— 2L REVIARICS
County P=1 Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secands or decimal degrees:
(ifwall field,one latliong is sufficient) q 22.Certification:
rq •
*3 IT W
1 &zep
A
6.Is(arc)tlt0WcI1(S)0Pcrmartcnt or OTempormv signature of Carl! Well Contractor Date
By signing this fann,I hereby certify that ilia siriffisi was fiveral consinxted in accordance
7.Is this a repair to an existing well: [)Yes or E)No with ISA NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill Olt,knolla,wall construction informadan and zq)laill the Outure of the cop)'of ibis record has been Provided to the wall Owner
repair under 021 rentarix section or an ilia back of thisforTn. 23.Site diagram or additional well details-,
G.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the some You may use the back of this pageto provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SbBIMTTAL INSTRUCTIONS
9.Total well depth below land surface: —(f 24a.For All V011s Submit this form within 30 days of completion of well
rar Inuttiple wails list all depths Y"differen r ralrampte-3@2 ov and 2@ 1001 construction to the following.
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
T ivater/oral is abova casing,use C 1617 Mail Service Center,Raleigh,INC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For infection Wells In addition to sending the form to the address in 249
12.Well construction method;
rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following.
(i.e.Nagar,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYv% LLS ONLY: 1636 Mall Service Center,R21elgh,INC 27699-1636
pressure 13a.Yield(gpm) Method of test: air p 24c.For Water Supply&inlectioni Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granular I
Amount: completion of well construction to,the county health department of the county
where constructed.
rom GW_1 North Catalina Department of Envirotanentai Quaiity-Division ormater RCSOUMCS P evis c d 2-22-2016