GW1-2022-06230_Well Construction - GW1_20220701

MINE
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Gox-veil O aLQSe •14;.WATER ZONES;. . ::: ;_',•
Well Contractor Name �" *116
DESCRIPTION
ft. fL
igs
NC Well Contractor Certification Numbef
l mlfi-casedyells)O1Z ISNE)tC�f'a'liraI�le)'v:Morgan Well&Pump, Inc. DIAMETER z� lavE 6118/ in' sd21 pvc
Company Name �! ` h 16CMINER SIlRGOR•TOBII�G''eotliermal"clo'sedloti
2.Well Construction Permit#: 'v) ` v FROM TO DIAMETER TMCIC ESS MA•rE12IAr.
List all applicable well construction perm its(Le.VIC,County,State,TYmiance,eta)• ft• ft in.
3.Well Use(check well use): f. ft rn
Water Supply Well: 17_-SCREEN'.-::::_:. .'• .'•._•_.: '.:'%:.• s',:�•:.:..,.--::".. ::;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
!Agricultural CjMuaicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft fL
I Industrial/Commercial Residential Water Supply(shared)
'Im ation FROM TO MATFRTAL EMPI kCEMENTMETHOD&_AM0II11T
Non-Water Supply Well: 0 ft 20 ft benton!te- poured
Monitoring IlRecovezy ft ft
Injection Well: ft ft.
_!Aquifer Recharge E!Groundwater Remediation
A nifer5tora eandRecov �,Salmi Banier ''�'SANn/GRAYELPACK rfa"licabr'e
q g ezy ��'• ty FROM TO MATERIAL ;. .EMPLACEI�NT METHOD -
AquiferTest 13StormwaterDrainage ft ft
PEeoth.
erimental Technology �1Subsidence Control ft ft.
thermal(Closed Loop) Tracer :ZO.DRIILING]LOG'(zttacri°additiorisI seetsifneces's 7':+r
rmal(Ileating/Cooling Return) J Other(explain under r#21 arks) I'R^ R To � c m DESCRIPTION( �hardness,soillrock type,grain size,ete.)
6 ,r
4.Date Well(s)Completed: Well ID# C7 ft ft
1 ft � Q/J
1 5a ell Location: D
f (� ft ft CM,
F ility/OwKneerName l� Facility M#(ifapplicable) ft ft
I�'I 1N��J���.� �� M_f IAH ft ft
Physic dress,
`Ciity,and Zip II n ft ft 'v`tR t<.v'�..�a `.' k__a,J
uklP� V� Y `' / .I��� 21:RErl�auuc� "<r;.- `r7 - -
County Parcel IdenJtificavtionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: {11;ci'j•»C =O �' 1=sx3.t :;� l nit
(if ellje}d,o�I tpo pg is sufficient) 22.Certification:6_57 V •• `f:1.4i,��1�
6.Is(are)the well(s) Permmmanent or ©'!Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Aj No with 154 NCAC 02C.0100 or 15ANCAC 02C,"0200 Well Construction Standards and that a
IJihis is a repair,fnII out known well construction information and explain the nature of the copy ofthis record has been provided to She well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details
8.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 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drMed. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ���• (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 rb 00'am12@100) construction to the following.
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
.IJwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y LI construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuDDly&Injection Wells: In addition to sending the form to
/J the address(es) 'above, also submit one copy of this form within 30 days of
�y
13b.Disinfection type: rt C yJ G r' Amount: /d Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of WaterResources Revised 2 22 2016