GW1--07840_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
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• '_WWATER'ZONES: t ;i•Zit;:i '. ',.W r i_,t;.':.,[,<iniii.AI.i!i?-2._.=i ti?€k l
FROM TO DESCRIPTION '
Well C tra tor Name 1 55 ft. �5 1 ft A^
34 ft ft �P
NC Well Contractor Certification Number v.. •
1r'S$S;O,TITER,GASING'(fa`nnulfi:cased_wells),OR!IIlVERs(iLap-licalile)Y�z s's(;`Ni4Qat.
• Morgan Well &Pump, INC FROM To DIAMETER ' ' THICKNESS MATERIAL
1 ft. 1�Q ft. 61t8 i' ' sd21 pvc
Company Name• ` (0� L v
`,\* 16c.INNERCA51NGiOR;T[JBING.{geotheim'alclosed;ld'op�.z, c=:"r
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.
z:l7 SGREEPIc.".`i'*," i,''.`-s:y`r.*M •�':'':'::,;i i>;` zz ..;: .. ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
Al Agricultural DMunicipallPublic ft ft. in.
•Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
i i _ ,.IndustnaUCommerclal �Restdentral Water Supply(shared) sg•:GROTPT!L. . ' `
r ,I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 0 ft. 20 ft' bentonite poured
*Monitoring )Recovery ft. ft. •
Injection Well: ft. ft.
ElAquifer Recharge 0Groundwater Remediation .-•.
sg19:SAND/GRAVEL.:PACK(itap"p"licable);.1 :e''?' ..- 1: `•y "-
QlAquifer Storage and Recovery DISalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ili Stormwater Drainage ft ft
Experimental Technology DSubsidence Control ft. ft. •
DGeothermal(Closed Loop) DITracer i28 D GROG(etfaeli"additional:sheets''ifnecessary)'`<';<; -i1•wiir=;;.i:?
FROM TO DES N(color,hardness,soil/rock type,grain size,etc.)
In Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) Iti ft 14j ft. `y
4.Date Well(s)Completed:\\\(.o \' 3'Weil m# 2•43 it c) ft. ,L• Yab3h dtr4c '
5 Well L catio d ft. 41 n: II'' 5 ft. i�lJ�h
s 1'�` rj S ft. atS ft. C J lc6e roc,
Facili /Owner Name Facility lD#(if applicable) (1 5 ft ' -r/C ft. blot._
t3�4
1-1%3b`e• .Itu,, `� -.*R .W .N( Z$V3g' ft. ft.
ft. ft i -'��."+* a
P ical Address,City,and Zip 1I�1` t"y/ ,F ", fj��',
(.0 1 041 r2D'RTi 1.ARics .'_, -- >,.-... .•_. .- -?.:.,,, 'pz l: a't+*_
County . Parcel Identification No.(PIN) D E C 0 5 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1niorr3.Kht-n r •c a,.i✓ql
(if well field,one lat/long is sufficient) 22.C• .; cation:,— . v'QM
Ola
3 .54i'cg N Q) , 319 W2 1 a3
6.Is(are)the well(s)tPPermanent or Temporary ignae• ,>f ified Well Contractor Date
By s o'mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ®fNo 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: (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: tkt) (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) 3 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
granulated chlorine 0 Z. completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016