GW1-2021-01321_Well Construction - GW1_20210329

"^'&L L UUN5TI1IICTION RECORD (GW 1) For Internal Use Only: V
I.Well Contractor Information:
Chris Morgan 14.IVATER ZONES
Well Contractor Nome FROa3 TO DESCRIE1710\
3579 It. \ R.
NC Well Contractor Certification Number R• IL
Morgan Well d:Pump, Inc. FROM TO
CTTO fformdDti�e�RW Oar i s[ nMATERIAL
Company Name +1 R• 6 ft 6118 in. Sd21 pec
16.INNER CASING
" ORTUBING rnd-loo
Ee cHoe2.Well Construction Permit& I FROM O RTIgMS atareRly.
List all appl/cahle wall cousrr[nion pmmtr(Le U/C,Comnc State,YarinncC ercJ it. ft. in,
3.Well Use(check well use): R. fl. is
Water Supply Well: 37.SCREEN
Agricultural la Munici al/Public IFROat IL TO Dvatt�ER storstzE THICKNESS am a
P a
pomthermal(Hcating/Cooltng Supply) C11Residenrial Water Supply(single)
rO R. rm
4]I[ndustriallCommemial QlResidcntial Water Supply(shared)
It71a ID.GROUT
ahOn FROaI TO MATERIAL RAIPLACEatENT a1Cr110D@AMOUNT
Mon•R'nter Suppivv✓ell: 6 R. R,
contends poured
\•toniloring [!Recovery ft a
hljection Woll_
Aquifer Recharge =DRIPILLING
R,QlGroundwater RemediadonAquifer Storage and Recovery E]Saliniry Barrier CIC(B'a livable)
afATCR1AL RalP"IMMIENTa1ETHOD
AqulPzrTes[ DStolmwater Drainage ft.Experimental Technology QlSuhsidence Control ftGeothermal(Closed Coo°) []]Tracer attach additmool shoals it necessary)
Gcothcmlal(Heating/Cooling Retum) Other(explain under r'21 Remarks) ---H. sa. Let) 'N r'-
4.Date Well(s)Cnmple[edi ��"7 Wall ,,n1a .S ft. Z..v it.
So.Well Location: 26 R. �—a ft.
// Q s�ti
[�.4 U M4! {c ! (l nla d R. ft
Facility/Owner Name Facility lD7(ifapplicable) ft. ft.
g632 ft. I,
Physical Address,City,and Zip I ft. fr.
Ifle'h�P 21REa7ARICS (a q
County--T Pmeclidcntifieation No.(PIN) I,!H'R 2 9 L071
5b.Latitude and longitude In degreesleninuteslseconds or decimal degrees:
(ifwdl field one IaUlong is sufficient) .2.Certification:
3S, 2La86y 1,,_.90r6e7V721 W
�. All _ Mare. 2�2�
6.Is(are)the well(s)�IX Permanent or QlTemporary signature ofccnirJ,fd Wall Cantmclor Doc
Bp signing rbir fo u.I Aerebu,hrr that the ve/!($)tvas(mere/constructed in accar'dmme
7.Is this a repair to an esistiag well; Dyes or )Ni o mid,15d NCaC 02C.0100 or 15:1 A'61C 02C.0200 Nell Conztntcrim,Smadard.,and Mar a
Ifthu'ts a repairfill ouIA710uD mdl ronsrmcdon information and explain the nature ofdu.• capj,ofNis reeordharbeen provided!,theuvli.utter.
repair under'21 remarks sec(ian or on the back ofdtis(orn:.
3.Site diagram or additional well details:
S.For Geoprohe/DPT or Closed-Loop Geothermal Welk bovine the some You may use the back of this page to provide additional well site details or well
construction,only I GW-I is n6etied. Indicate TOTAL NUMBER,£wells cons raclion details. You may also attach additional ages ifnecessary.
drilled: ' r 6,c)
SL3�TT.4L INSTRUCTIONS
9,Total e depth below land surface: 7 (fL) 24a, 'Car All Wells: Submit this form within 30 days of completion of well
[--at' units list all dcptlrs ifdyerem(ernntple-5@20m'mtd 2@I001 conStmCdOn to the following:
0.Stndc Crater level below top of casing: Gf� (£L) Division of Water Resources,Information Processing Unit,
11. te,Bo level is e above ter: toe"+" 1617 Mall Service Center,Raleigh,I IC 2 769 9-161 7
II.Borehole diameter: G (in.) 24b.For iniection 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,cowry,cable,direct push,etc.) construction to the following:
Division of Water Resources,underground In ection Control Program,
FOR�irATIsR SUPPLa!%jTLLS Oi4Zi: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnl)� Method of test, air pressure 24c.For:Pater Suoah•E iniection iVells: To addition to sending the form to
l ranuar the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection kTpa: g Amount: to b�_ completion of well construction to the county health department of the county
where constmcted.
Front G1:'-1 North Catalina Department ol'Enviroomentai Quality-Divman or Water Resources Revised 2-22--2016