GW1--07653_Well Construction - GW1_20231204

' WELL CONSTRUCTION RECORD (GW41 For Internal Use Only: •
1....W.3Wai
ontractor Information: ^�
1�4� .1 +WSJ] 'K.k?•:`3y_v%:gi.SY'.YS?i=t7'i'.'•.S"X 2'.-+P.' �•e- Q`rS:`V'.�O'AtYx CX'� Y3:c3,�.s:
FROM TO ESCRIPTION
Well Con Name 15 ft t. A •
I ft. 1g`s fft. J .
NC Well Contractor Certification Number •�^"" a- .
' ',�`jIO,U).t°k:1ZiQASI1!1GV(formulti�cgs"'ea,°�we11`af�OI��DEt;(i lica"�le�.°'�''°'.�.'�-'_,a
Morgan We11-&Pump, INC • FROM TO DIAMETER THICKNESS MATERIAL
1 ft 1 ft 61/8 ; in• sd21 Pvc
• Company Name. r_1bs ` `l- ' _ftM—at.a R=
/� q^'' q rG G'�oR:l[t2S eotherma"I'rc"'1.oee�ee 'TA.
2.Well Construction Permit#: U P�r 633 ( FROM. TO DIAMETER TRICKNZSS MATERIAL..
List all applicable well construction permits(Le.TJIC,County,State,Variance,etc) ft. ft. .i. in.
ft. ft. in.
I.Well Use(check well use): .
4.1V S XINti 3 ; , %fit
Water Supply Well: • • FROM TO • • DIAMETER SLOT SIZE -THICKNESS MATERIAL
Agricultural inMunicipal/Public ft. .ft. in. . -
Geothermal(Heating/Cooling Supply) //Residential Water Supply(single) ft. ft. in.
J Industrial/Commercial Residential Water Supply(shared) 8� 0� ate . i'3 ,
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring DRecovery ft ft 1
Injection Well: •
ft ft.
Aquifer Recharge - C Groundwater Remediation - ArIR L tVya liable ;. ,n —_ -
,
©I Aquifer Storage and Recovery jSalinityBarrieI FROM TO MATERIAL EMPLACEMENT METHOD
$Aquifer Test ©IStormwater Drainage ft ft. -. .
DExperimental Technology.. [ Subsidence Control ft. ft.
,a aa, 3sr
Ell Geothermal(Closed Loop) QIJ Tracer 20IFp or o. (a ch'a' artlo ._e. eetr'.:_ecea.ayg)
FROM TO DESCRIPTION(calor,hardness,seillrocktype,grain size,etc.) ,
rit Geothermal(Heating/Cooling Return)^�IJ Other(explain under#21 Remarks) ft. 1� ft. wy, 1�4
4.Date Well(s)Completed:it(l3 I2-' Well ID# - -I5 ft. 55 ft. t�C W� (r e,,,b...
55 ft. 115 ftslinith �► �'
Sa.Well Locatio �s ft ft. rnr` 1 „ t ,�Q
•
acility/Owner Name • Facility ID#(if applicable) 165 ft. ft. Uy. ►rr`4^
C 1 v 'ftwitsV k f o Afc-2S116 ft.
t v�+ ft. 17 V�••�+I+
t `(iv ft. ft.
Physical Address,Ci ,and Zip
County ParcelldentificationNo.(PIN) e „ , \\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation: -- ! D E r 2023
341
6.Is(are)the well(s) %/Permanent or OI Temporary
Signa o rtified Well Contractor DD i;ice JCY`;r 'Date
By ' ing s form,I hereby certify that the well(s)was'(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 154 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 TOTALNUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:' • SUBMTPTAL INSTRUCTIONS •
9.Total well depth below land surface: —1 v (ft-.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the followin
g i
I'
10.Static water level below top of casing: 45 (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 Olt) 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
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 -
13a.Yield(gpm) 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: granulated chlorine Amount: ig 6 completion of well construction to the 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
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