GW1-2021-01999_Well Construction - GW1_20210620

w r,L tJ 4r UNS` RUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: � f%
Chris Morgan 0 14.W9TERZONES
Well Contractor Name FROA1 TO DESCR1PTiOtY
ft. rt.
3572 N
\1
NC Well Contractor Certification Number t'(nG '.On
QGl• 16.OUTER CASING(for multi-cased rvells OR LSNER(if, ttcable)
Morgan Well G Pump, Inc. ¢J((;3`'�1�� I'ROM TO DtAP1ETER THICiQ U MATERIAL
+1 ft, ft. 61/8 in' sd21 pvc
2.Well,Construction
/ �
Jj� 16.INNER CASING ORTURING( eothermat closed-loop)
2,t�Vel!Construction Permit#: FROM To I DfA61ETS11 I Trlrcrwrss 111,ITSRlu
List oll applicahle❑-ell constntction permits(i.e.UIC,Cotntrr.Stare,f'ariance,etc.) fL ft. in.
3.Well Use(checkivell use): ft R. in-
- ater Supply Well: 17.SCREEN
FROM I TO I DIAMETER I SLOTSIZE I TIIICltlTM I MATERIAL
Agricultural MMunicipallPublic ft ft In.
Geothermal(Heaimg/Cooling Supply) Residential Water Supply(single) ft. It. in.
[�Ilndustriat/Commercial DResidential Water Supply(shared) 18.GROUT
fnigation FROM To I MATERIAL CNIPLACENIL•NTP1GTBOD&An1011
Non-Water Supply Well: o fr 20 ft' bentonite poured
Monitoring ]Recoicry fL ft,
Injection Well:
ft, ft.
`Aquifer Recharge 01Groundwater Remediation 19.SAND/GRAVEL PACK if 2policablel.
Aquifer Storage and Recovery []ISaliniry Barrier FROM TO NATERIAL FNIPLACENIFNr METHOD
Aquifer Test Ostormwater Drainage ft. ft.
Experimental Technology E]ISubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer ?A.DRILLING LOG(nttach additional sheets If necessary)
FRDM TO DESCRiPTr 4 color.hardness,soillroch!t•c,erain siza,etc.)
Ceothcmlal(Heating/CoolfngRetirm) Other(explain under,�2lRemarks) ft b Ft
.r
4.Date Well(s)Completed:,6 2� Well 1D#n/a b tt. ir. w r
Q �V f
5a. ell t.aeation: ft. t,
RJS n(a b fr. fit.
Facility/Ot erNamc Facility ID'(if applicable) ft• I ft.
e�C'r ( c �,o ft. ft. —
Physical ddress,City and Zip ft. ft. —
'tn Cr_')Cr_')lti C� / /-7 21.REMARIU9 _
Countv PatcclIdcntificationNo.(PIN) —
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
'_MDq8q N st 7 W U.,
6.Is(are)the well(s)0Permanent or [ Temporary signature ofCcrtTfj!"d Well Contractor Date
G''
Bj>signing this forth.1 hereby certifj,that the wall(s)teas(were)constnicied in accordance
7.1s this a repair to an existing well: DYes or n I-lo ivilh 15I NC4C 02C_0100 or 151 NCAC 02C.0200 Well Con-vinfelion Standards mid dial a
If this is a repair,fill out known well consinicdon information and explain the nunire of the copy of this record has been provided to the}cell owner.
repair under 921 remarks section or on the back ofthisform' 23.Site diagram or ndditionai well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 G�V-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' SiJBM1TTA.L Pn1STRUCTIONS
9.Total well depth below land surface: M-) 24a. For All Wells: submit this form within 30 days of completion of well
for multipla wells list all depths lfdiereni(erample-3 208'mtd 2@100� construction to the following:
10.Static it'ater level below top of casing: 116 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 IM-ail Service Center,Raleigh,111C 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection'Wells: In addition to sending the form to the address in 24a
rata ry above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 ;4iethod of test: air pressure 24c.For Water Supple&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 trpa: granular Amount: completion of well construction to the county health department of the county
=4�� where constructed.
Form GIN-1 :North Carolina De m
Department ofEnvironantal Quality-Division ofelrater Resources Revised 2-22-2016