GW1-2022-10229_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information: r
'14:.WAT'ER Z0M1
FROM TO DESCRIPTION
well Contractor Name ft ft
fL ft
NC Weh Contractor Certification Nuoriber 1g;OUTER.t g5�*G,(fac multi-rasea`.ins)ORLSTF 2(rt - bra}=v::"::.•.: .`.:
Morgan Well &Pump, Inc. FROM TO'. DIAMM11 I x> CKNEss MATQRTAS-
+1 ft I
1b ft 61/61 sdr21 pvc
Company Name = ;'
ld'II�R CASING OR•TIIBII�IG. •eothermal•clo'sbd-loci
EPJAL
2.Well Construction Permit#:•�92 ! 7 1 r� FROM xo s 'T
List all applicable well construcdon pernuts'(�C, onnrv,State,Variance,etc)*
ft fL
3.Well Use(check well rise):
Water Supply Well: 17 SCREEN o:.: -.D'^ _SLOT SIZE: CIOSSSl •TTr1ATERTAL.
Agricultural Mi Municipal/Public
Geothermal(Heating/Cooling Supply) MResidential Water Supply(siilFle) fc fL
Indus Commercial !Residential Water Supply(shared)Of
18'GRRl1 _''
Irrigation FROM TO MdTFRTAL EMPI4CEMENTTr=0 &AMOUNT
Non-Water Supply Well: o fL fL bentonite
Monitoring opecovery ft ft l'
Injection Well: ft ft
Aquifer Recharge �!Groundwater Remediation _ r•; ::•::•:
.19: _11D/GRAVEL•PAC1(rf a'•linable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATFRrer. M PLACFd>t KT 1,ETgOD
Aquifer Test OStormwater Drainage ft ft
I Experimental Technology Subsidence Control f ft 1
Geothermal(ClosedLoop) OTracer :28.DR1LTTBIGLOG'(attach'sddition'sls7ieets�fnecess"7'' %'=s -= • .' '
FROM TO DESCRIPTION(color,hardness,sourrocktype, in size,etc)
Geothermal(Heating/Cooling Return) .�Other( lain under#21 Remarks) © ft
ZQ ft.
I
Zy_ b
4.
4.Date Well(s)Completed: `- Well ID# fL I Q�
52.Well Location: R
Ram 1 nee -7. °iy` ft. oo r .1 .
Facility/Owner Name FacilittycIDN('ifpappplicable) .} ft
fL ft.
Physical Address,/Ciity,,,and
Zip ft
M
County Parcel Identifi-ti—No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lla�att/J/long//is sufficient) 22"Certifira
Sim o Certified Well Contractor Date
6.Is(are)the weIl(s)�l%'Permanent or �Temporarp By signing this form,I hereby certify that th j e wea(s)was(were)constructed in accordance
7.Is this a repair to an existing welt ©Yes or RyI No with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair fin out known well construction information and explain the nature of the copy ofthis record has been provided to the xell owner.
repair unnder#21 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 NUh0ER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-1W 00'and 2@100) construction to the following:
10.Static water level below top of casing: ( (ft) Div_i_sion of Water Resources,Information Processing Unit, -
•Ifwater level is above casino use"+" 1 3617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) ` 24b.For Iniection'Wells: In addition to sending the form to the address in 24a
( above,also submit one copy of this form within 30 days of completion of we
12.Well construction method: 0 L! ll
construction to the following.
(Le.auger,rotary,cable,direct pusk eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VVFLLS,ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 1 J Method of test air pressure 24c.For Water Supply&Injection 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" CJC)1^ ,,1-e! Amount: , 0 completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofFnvironmental Quality-Division of Water Resources Revised 2-22 2016