GW1--05720_Well Construction - GW1_20230905

Paint=:Foam
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
4.Well Contractor Information:
1 •
?14:WATEIVZONES_t. Xm,t "e_: l• I. . ...
Well C tm tor Name CAS
o, DESCRIPTION
�y�ft IIft ,5 � M,
3�42z-- l bitI , ft 0 P \ H
NC Well Contractor Certification Number 4
si.15rOiJTER.CASING:(formolti;ca"s°d'ell'sj'.OR`LINERXiifa"p ia`lile)'°,: " -.' .
Morgan Well &Pump, INC FROM DIAMETER i THICKNESS MATERIAL
1 ft. 'C) ft. 6 1/8 'm• sdr21 pvc
Company Name• • l� ,
01.+� � _ ^ ;::16IPIIPlEI CAS .GOR;TUBING'(Reotherinal"ciose loopi)a_ 3g:.i ; ,-
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft 'in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: ;.17 SCREENc
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
jAgricultural _ f Municipal/Public ft ft. in.
'-I Geothermal(Heating/Cooling Supply) ittesidential Water Supply(single) it ft. in.
Industrial/Commercial *Residential Water Supply(shared) ;18:GRODT ac' `.i s<
i rigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite I poured
Monitoring DRecovery ft. ft.
Injection Well: • ft ft ,
*Aquifer Recharge Groundwater Remediation
;f;.19i.SAND/GRAVEI:-PAC&"(if:applicable)�Y_? '.. ,?..-f:, , - - _
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test . EllStormwaterDrainage ft ft.
%Experimental Technology 0ISubsidence Control ft. ft. .
Ri Geothermal(Closed Loop) DTracer .20 D .1NGLo'G(attiel additioiiii:s-lie`ets iniaeisiryMis=_- " _. r
iti Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRTIO}V(color,hardness,soil/rock type,grain size,etc.)
•�/�( �c/'j�ft tt. �� al rr _
t I /I)3 cam• t4 .)itbr 1 4-4.Date Wells)Completed: Il Well DV d`�
54.0yell Locatiorllli L v1 ors- j�t f�ft Wit.
_J'�t baj ch roc —
,a,Y J •Y A\{0 &Z)h i litil `(c_oft 11JlS ft• alrc.+a- _i�i1�,.,,,VL
Facility/Own rI e Facility ID#(if applicable) c ft. ft. �,`"-t-• ,—t i---, v
t".
5G.0%) ekAckcve,'(2.- brbyka-tf, NIL ,v) ft. ft
Physical Address,City,and Zip ,2;C ft.
ft iSF
P
nfr.t..1-6Akt) \1..]r je3.,.1� a2SCREMARKS.'.•,:..::._'_:S?...... -.. .. . ..: _.->....?::Arii.c.,..� , ; i.
County - ParcelIdehtificationNo.(PIN) illiroritf'. tC�1 Pri .t��r�.
✓1rJ LJOQ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if��d,one is sufficient) � 979)-
22.C cation:
•6.Is(are)the well(s)*IPermanent or Temporary Signal red Well Contractor *,,2 :3
By s: ing th 'rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or *No with 15ANCAC 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:1 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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (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: 1
(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 2769 9-1 63 6
13a.Yield(gpm) as 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: 17(�p�7. completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016