GW1-2021-03024_Well Construction - GW1_20210527

Vvffi,Ila1L cl:ONST&UCTION RECO LqW-1 Forintternai Use Only: ... ,y ..
i
I.Well Contrnctorinformuti0n:
Chris Morgan 14.WATER$oiYEs
Rleil Contractor Name t)RI TO I DFSCRUMON
3572
ft. ft.
NC Well Contractor Certification Number
1&,GUT'Ett CASING(for motti-:used iveIIs 4i2 T.iNER(ir nc�ablo)
Morgan Well&Pump, Inc. moat TO DL1atETER Tt3ICJOLS MATERIAL
Cumpatty Name +1 ft. ft. 61/9 in sd21 pvc
f/ L .16.INNER CASING ORTUBING(eotherrteai closed-loo
2.Well-Construction Permit#:7_U C CU f r•Ront TO DLiMETER Ttuelc.tEss MATERIAL
List all appilcahle cell constrrtelion permits g.e.U1C,Courgt:State,irarlatim etc.) fL fk. in.
3,Well Use(check well use): it. ft. In.
Water Supply Welt: 17.SCREEN
t
FROM� rt. n To DIADSEf In. ST f SIZE T111CLMIM litt%TERtAL
Agricultural �Municipal/Public
Geothermal(Heating/Cooling Supply) QlResidentiai Water Supply'(single) ft, ft, in
Pindustrial/Commercial DResidential Water Supply(shared) 10.GROUT
F' Ilrrigatidn rRO1v1 TO MATEMA.L 1-M1IPLACEM.ENTPiL•THOD&AntOUtv'T
Non-Water Supply Well: a ft- 2a ft. bentanite ! poured
Monitoring ORecovery, R, n
Injection Well:
Aquifer Recharge oGroundwater Remediadon
- Aquifer Storage and Recovery 1S SAND/GRAYPL PACK
A i£a iicabic}.
$ g ry DSalinityBarrier FROM TO 6tATERtAL EAtPLACEPfENTMETHOD
Aquifer Test Dstormwater Drainage ft. I ft.
Experimental Technology DtSubsidenee Control ft. ft.
t F
Geothermal(Closed Loop) ClITracer 20.DRIf.LING LOG(attach additional'sheets if necess )
Gcothcmlal(Heating/CoolingRetum) Other(explain under:r22Remarks) FROM TO DESCRIM0.tcatanhardnemsolurucht aaaiosimeir)
ft, �fk. � �
C- ) , r
4.Date Well(s)Completed:3_/�� f GYeft lI3#niB 6 ft. V fr. f
So.Well Location:
n!a fr. rt.
Fa iliry/ w'nerNaamei-, p / Facilityipr(if applicable) R• ft.
W•`� ' ? fl t QI\V"�✓ ft. ft,
physical Address,City,and tip ft. ft. ;v.,,/-
J F 1
lr t �V 1 �lC?{,,�j x 21.REMARKS pp
County Parcel Identification'No.(PIN) Id
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t_
,, GCgcSIn i111A
(ifvtcil field,one t t/long is sufficient) 22.Certification. D\ tZ S5^tlOn
6.Is(are)the well(s)OPermanent or OTemporary Signature of Ccriii Eld Wall Contractor Date
B3rsigning ribs f0art,f Itereb}�cert �that the zrell{s)was(izere)consinreted in accordance
7.Is tttis a repair to an existing well: Dyes or E)No mlth 15A NCdC 02C.0100 or 15.4 AICAC 02C.0200 Well Constntcavis Standards and that a
Phis Ir a repair,fill ant larotvit well consiniction information and erplain the nantre of ilia copy oftbis record hos been provided to theivell owner.
repair under#21 remarks section or on the back ofdtis fort.
23.Site diagram or additional well details:
G.For Geoprobe/DPT 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-t i;needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' (,� SUBMITTAL P. STRUCTIQNS
9.Total well depth below land surface: ` (fL) 24a.For All N'4'ells: Submit this form within 30 days of completion of well
Tar mttkiple%sells list all depilts l,(dfflerent(example-3@200'a_njd,.2@100I construction to the following.
10.5tatic water level below top of casing: ` (ft.) Division of Water Resources,information Processing Unit,
If ti rrer level is above casing,use `t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method;
construction to the fallowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR W 4TER SUPPLY WE,LLS ONLY, 1636 Mail Service Center,Raleigh,NC 27699 1636
13a.Yield(gpm) ^ _ Method of test: air pressure 24c.For Water Surmly&Iniection[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 Amount: completion of well construction to the'county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division or Water Resources Revised 2-32-2016