GW1-2022-10213_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Chris Morgan Ala wax>RzoivEs . »' z4 . .w s«
FROM TO DESCRIPTION
Well Contractor Name Q Q M
-1-1 ft. 106 ft. f
3572-A 1_I
'S6 ft. L I
NC Well Contractor Certification Number „15 OUTEIYC$SING formulUtased;_wells:ORUNER'>f:a`'licable t,
Morgan Well & Pump', INC FROM TO DIAMETER' THICKNESS MATERIAL
ft. 9q sin.
Company Name
It c fNNER C A$ING OR—'TIIBING''°eothernial86i6d-lob
2.Well Construction Permit#: 36���� FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,,State, Variance,etc.) ft. tn•ft.
m
3.Well Use(check well use): ft ft
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural icip 6?.ide.tal al/Public
ft. ft. in;
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
Industriaucommercial D1 Residential Water Supply(shared) 18:'GROUT tt =>
Irrigation FROM TO "MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
;19 SAND7GRAVEL�PACK`rf a` licalile „�� :, "
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer -20 DRI=%, LOG:(attachiafld1tion'a"1 sheets if aecess €4 1
FROM TO DESCRIPTION(color,hardness soillrock type,grain size,etc.)
_!Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. (J6 tt. 4ek
4.Date Well(s)Completed: 10—Z5-72- Well ID# (41 ft• 75 ft. owe C(
gG ft. 2� ft. Ya Y l
Sa.Well Location: b
S&scvx 5&jVe•
Facility/Owner Name Facility
DD#(ifapplicable)
Physical Address,City,and Zip IfliOfglr�'jXI 2 �r
gowavx q32 (09 3i:'REMARxs F3 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C fieati
35.53 y 6 N --%6 447W W
6.Is(are)the well(s)oPermanent or OTemporary Signature of Cedifie e 1 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: []Yes or X)No with 15A NCAC 02C.0100 or 15A NC.1C 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this 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 if necessary.
drilled:' SUBMITTAL INSTRUCTIONS',
9.Total well depth below land surface: Z60 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 3 O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection 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 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) Method of test: Ag 1V 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit;one copy of this form within M days of
13b.Disinfection type: chlorine Amount: 1?6Z completion of well construction to the county health department of the county
where constructed.