GW1-2021-04741_Well Construction - GW1_20210527

vt'ER tlL d:QM . . ,IET IT��TON RECORD(GW J� For Internal Use Only: j ,. -
1.'tWell Contractorinformation:
Chris Morgan
�
Well Contractor Name 14.WATER ZONESrROM TO I DESCRIPTION
3572
NC tVell Contractor Ceri ficadon Number ft. ft. e
r
Morgan Well&Pump, Inc. iS.,OIITGti CASING(far multi cased webs OR LINER f. ncablo
IROM1f TO DL1M1TETER THICICNESs MATERIAL
Cumpany Name +t ft. It. 6116 in. sd2t
pvc
336oxg 16.INNERCAS INC ORTUSING(geothermal closed-loo
2.Well'Construction Permit#: ! FROM To DfABIEfER THiCIfNESS a1ATERIAI
List all applicable c ell construction permits 0 a UiC,Count;State.Variance,etc.) ft. ft. in.
3.Well Use(checitwell use): ft• ft to
ff
ater Supply Well: 17.SCREEN
Agriculturai FROM TO DIAM1iE7ER SLOT SIZE TH[CI�ESs M1L1TEtAL
�MunicipaUPublic R
ft ft. tn.
OGeorhermal(HcatingiCooling Supply) bResidential Water Supply-(single)
pindustrial/Commercial rt ft. in.
QlResidential Water Supply(shared)
Itligation 10.GROCT..
r•ROM1f To afATEttL1L EhiPLACENIENT DIETHOD AANOUnT
Non-Water Supply Well:
Monitoring 0 rt. 20 ft. bentanite poured
011ecovcry
Injection Well: R- ft.
Aquifer Recharge DGroundwater Remediation ft.
Aquifer Storage and Recovery QlSalinity Barrier 19.S aND/GRAVEL PAIL ifn licable).
FROM TO MATERIAL ENzPLACEntENTN1KTH0D
Aquifer Test DStormwater Drainage
Experimental Technology E)Subsidence Control
ft. rt.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets if necessary)
Gcothcrntal(Heating(Cooling Return) Outer(explain under 2l Remarks) OM1f TO DESCRIPTION color,hnrdness saillracl:it a peaia stzG etal
c b ft. Zo ft.
4.Date Well(s)Completed: J S Z well ID-4 Na ZO it, — ft.
h Ir
Sa.Well Location: 3 rj ft' ft' h ra
J�h l t, t�Vi1e S n!a O ft. U ft. lam •
Facility/OtvneriVamc Facility lD0(ifapplicable) ft. g,
a V It. ft
Pl skal Address,City.and Zip tt. g, i �+
n/a .21.RENARICS •.p•
County Parcel Identification No_(PIN) I AV TMT
H t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rnrcacgjt"t,. Unil
(iftveil field,onelolot/long is sufficient)
e'U. ���� 22.Certification:_
lQ N d W
iI l. .1 -- S
6.Is(are)tile welgs)OPermanent or OTemporary Signature ofCerttfjkd Wcll Contractor Da(c
7.Is this a re air to an e Q Bp signing this fornt,I hereby cert�,that the Wa!1 s)'vas(there)constructed in accordance
p xistint,well: DYes or 2)No with 15A NGAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standardr and that a
Phis is a repair,fill out known well eonstnrctlon injonnathan and explain the nature oftha copy of this record has been provided to the cell oumer.
repair under#21 rumarla section or on the back of thisjorm.
23.Site diagram or additional well details:
S.For Geoprobe/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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: '
�l�D SUBMITTAL INSTRUCTIONS
rface
9.Total well depth below land su . RP 24a.For All «'ells: Submit this form within 30 days of completion of well
ha-uutltiple wells list all depdts IJdrferenr(en imple-3@700'and 2@l001
)�Ijxvter level is above casing,are construction to the followmg:
10.Static seater level below top of casing: �( (ft.) Division of Water Resources,Information Processing Unit,
J ^t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 fin.) 24b.'For iniection Wells: In addition to sendine the form to the address in 242
12.Well construction method- rotary above,also submit one copy of this iform within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR W STER SUPPLY`74,ELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 v Method of test: air pressure 24c.For Water SuDDly&iniectio I Wells: In addition to sending the form to
the address(es) above, also submit Johe copy of this foam within 30 days of
13b.Disinfection ripe: granular Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-:2016