GW1-2021-01982_Well Construction - GW1_20210620

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Y/ttELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information: n
Chris Morgan '.� 14.LVATERZONES
Well Contractor Name FROD1 To DESCRIPTION
3572
NC Well Contractor Certification Number Jv nf✓eSs�(�� 1S.OUTER CASING(for multi-cased wells OR LINER ifa itcabl)
Morgan Well&Pump, Inc. �`CgGC4x IRON I TO Df.1c11ETER C�Cf4YESS hfATCItIAf
Company Name V{r, QN +1 ft, ft' 6118 in• sd21 pvc
�,—/) 16.INNER CASING OR.TUBING(geothermal closed-loo
2.Well'Construction Permit#.W / tis 2oZ�—/S�OG3� MONT To DIAtNETER. I THICKNCSS I IIArERIAL
List all applicable well constriction permits(Le UIC,Cowry-.State,Variance,etc.) fL ft. in.
3,Well Use(checkivell use): R. ft. In.
Water Supply Well: 17.SCREEN T
ITtONT TO DIAMETER SLOTSiZE THICICNESS i1 ATERIAL
Agricultural MunicipaUPublic It. It. In,
pGeorhermal(Heating/Cooling Supply) ( esidential Water Supply-(single) rt, rt.
Ilndustrial/Commercial Residential Water Supply(shared) Ill.GROUT. —
Inigation FRONT To IIATERML ENIPLACENILNI•NIE•THOD&AniounT
on-Vttater Supply Weli: o Cc 20 ft. bentonite poured
Monitoring ORecovery fL ft.
Injection Well: _
ft. ft.
(Aquifer Recharge oGroundwater Remediation
offer Storage and Recovery 19.SAND/GRAVEL PACK if applicable)
A
9 g ery QlSalinity Barrier FRONT f To I4iAT ER(AC. ENiPLAcr.NiENrmF-rHOD
Aquifer Test OStormwaterl)minage ft. ft.
Experimental Technology (Subsidence Control fc. tt.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks) 1 FiMOai To DESCRIPTION color.hardness,soil/rock li e,Emin size,etc.)
Oft. ft.
4.Date Well(s)Completed:ClZ�til Well 1IYr n/a ft. Z s ft. {Of,a� �, r
S..a��Well Location: 2ca ft. S'0 ft, bJ� t
�O�dCc f` t eLt�- nla C^+
Faciliry/OwncrNamc Facility iDr(ifapplicable) �pG fr- op ft. A)k fG
_q�60 4.pr_J ;;CJQ,, ft. ft.
physical Address,City.and Zip ft, ft.
7C)3 yYIOX y 21.REMARKS _
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lot/long is sufficient) 22.Certification:
3S_S�Sosq �; --g 1 , a� l 8'�'6'
6.Is(are)the wou(S).^Permanent or Elffemporary Signature ofCcriifj8 Wcu Contracior is
By signing this roan,I hereby certo,that the irell(s)was(were)consinicied in accordance
7.Is this a repair to an existing well: DYes or XX No with 15A NC.4C 02C.0100 or 159 NCAC 02C-0200 Well Constritctiaa Standards and that a
#'this is a repair,fill oat known well constniction information and arplain the nature ofihe copy of this record has heen provided to the wadi oiimer.
repair under R21 rantarhs section or air the back of thisfornL 23.Site diagram or additional well details-
9.For GeoprobelDPT or Closed-hoop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW'I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: w V (tL) 24a. For All Wells: Submit this form within 30 days of completion of well
For•mtdtipla irells list all depilts Ifd�erent(erample-3@200' d 2,@I0q construction to the following
10.Static ivater level below top of casing: �V UL) Division of Water Resources,information Processing Unit,
I•nater level is above cursing,use•'-t-•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 followins:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY-iTLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1616
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuDDly&_Iiniection 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: v 0� completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of hater Resources Revi5cd 2-2r2-2016