GW1--04189_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
��/ rod i14 WATET2'7ANE5 yc : ._ `_ ._ , it
Well Contra r Name FROM TO DESCRIPTION
ft. ft. I I
ft ft ! '
NC Well Contractor Certification Number • 15 Offl'ER_GASINGs(foi iinilti,rasedlwells)OR T.TNFR,(rtap lrcable)rtt e ,.r.;•w.a.',
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ft 61/8 m sd21 pc
Company Name „ Y
�,, `]2 y� 163TN1VER.Ge15INGORxi7BING.(geothermalclosedloop7
2.Well Construction Permit#: l� �� `J vo �� FROM TO .DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in
Water Supply Well: 17fiSGREEN` 5 _ _ _
l FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 1 iResidential Water Supply(single) ft ft, in.
Industrial/Commercial II Residential Water Supply(shared) 1$ GRQUT X`s; x_ _. -- .f_i_ .` .•>r .-'''_'-:'i•-1--,f3.;-•;', -
(_)Irrigation FROM TO . MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
OMonitoring L._!Recovery ft. ft
Injection Well: - ft ft.
$I Aquifer Recharge DGroundwater Remediation _
19 IsP
,:SANDIGRAVEACK(ifapplfcalile) _
$i Aquifer Storage and Recovery in Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
$Aquifer Test 0Stormwater Drainage ft ft
•Experimental Technology in Subsidence Control ft ft
MI Geothermal(Closed Loop) DITracer 20 BRILL NG3 OG:(att"acliaddi4oriul`sheet ifiie`c'essary) .�: _.
FROM TO D�sSCRIPTION(color,hardness,soil/rock type,grain size,etc.)
•Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ^ ft [).v ft. �(QW^ �;r`-�-
4.Date Well(s)Completed: Well m# gJo ft 73 ft ( Ab iv/\ Q00
5a.Well Location: !) ft t 11c ft 7c�IB `k,• a ,'11 -
c /4// 7 ft ft ( 49
Facility/Owner Name �J Q Facility ID#(if applicable) ft. ft �J ��.F.1 v ,�r"`) •
/3 6o(i✓-15//CY e, // ft. ft. . '. L c L;o ;•/ 4-j a
Physical Address,City,and Zip ft. ft J( I l 0 n ZnL!L.r)3
),/� 21:RE1Vlmis-I;;e _. ,_ ,, {,. _ . _:
fJ 6f 1 knEv t c'l r �^T�''k i'I I
County Parcel Identification No.(PIN) j a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) y 22.Certification: •
55`6/� /Y N V, �/ '17 W 6- - z3
6.Is(are)the well(s) Permanent or ❑Temporary
Lx
Signa e Ce ed ell ontractor 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: j L—_Yes or 1No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If 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#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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 005 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii erent(example-3 'and 2@100) construction to the following:
10.Static water level below top of casing: �.19 (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 (in.) 24b.For Injection 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) _,.5 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: granulated chlorine Amount: G Q z completion of well construction to ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016