GW1--07841_Well Construction - GW1_20231205

WELL CONSTRUCTION REC
ORD GW-1 For Internal Use Only:
1.We Contractor Information:
;11.4WAIiSZQLVEs's: -Fa D •amon
®
FRO T®
WellC tra torName •
1112011ran eab Str �:i�S'vl
i ai'7li.. 1e.�s
G fairiultir :afiell's ,ORZ R•
'eFROM ER9C' D� 'THICKNESS NC Well Contractor Certification Number FROM
TO
Morgan Well&Pump,INC' GASU ORtUBI 'eathermal.closed?loos :`r=s K <. •: 5ss''
Org y1b;Il�iNE� CT' 11.0ER THI(S�san Name . 3 • C\ S V FRoT -
Comp Y
2•Well Construction Permit n UIC County,State,Variance,etc.)
3. all applicable well construction permits(i.e ®t ''� j aw'r'
IIIINIIIIINNIIIIIII
(check J7:SEREEDC"o 't-. i L'-' 'sLo==—
ell Use( well use): D�
WaterEMO
Supply Well: Dj Mnnlc1Pa blic ®®
NI,Agricultural {L iResidential Water Supply(single) ©® . ,.<-::s'x•.<s,;: :.;'•
Geothermal(miner g/Cooling Supply) a (shared) 1153 G O .'=:'•_ 4.-' EMrLACEnENr TEOD&AMOUNT
011110.11111101111111111.011111
f*1rriustriaUCommercial Residential Water Supply FROM TO
0
it. 2 f t.
*IIrriration ®®OEM
Non-Water Supply Well: DRecovely _
111111111111
*Monitoring ri.,.°:=,;+ie
Injection Well: •
(Gl;AVEI PAS lic�ble' :....,a IACEMENTMETHOD
l Groundwater Remediation .19-SA7`II). T�
11Aquifer St Recharge and Barrier FRo®
,J SalinrtY
•IAquifer Storage Recovery Ili Stormwater Drainage „
iiAquifer Test �� r._ .: '-t
ii
�I Subsidence Control c_-- ._. GY:pG.atfach�ad'ditionaTsheets•if.necessa ' `:�` -- ' 91�,eta
Experimental(Closed logy ,24;DR DgSitiaa�N color,hardness,soillrock I.e,=
�ITracer Fgomi To
*Geothermal HeatinLoop)/ of \d ft. egar` air
Cooling Return) *Other(explain under#21 Remarks) b it
Geothermal(Heating/ Lb ft 3 ft ►' fi. II _A' 1
l Well no — SO
d
4.Date l Locat Completed: `
®. 0., . A
nIIIIIIIIIIIIIII
5a.WellLocah'on:
cA VS
a5 ft �,
Facili VI(if applicable)
WC
Ne �-: IN
Facility/0
Physical Address,City,and Zip -Bs�6 01 A � _ _
t.
�1� Parcel Identification No.(P� '1
County � f7t4a:1c71 r�rn.t. _v(+alb
degrees/minutes/seconds or decimal degrees: 22 C cation: Gv'( LQ(aR
5b.Latitude and longitude in degreeslmin ��
•
(if well field one let/long is sufficient)
�� ��� W Date
N - �
Siva g 'fled Well Contractor
DTern orary th rm,I hereby certify' that the well(s)was(were)constructed in accordance
Is(are)thewell(s)*Permanent or p Byse mg
6.Is( ) with ISA NCAC 02CW Well
or ISA NCAC .020002C Well Construction Standards and that a
DYes or *No copy of this record has been provided to the C l owner. .
7.Is this a repair to an existing well: lain the nature of the •
If this is a repair,fill out known well construction information and explain 23.Site diagram or additional well details'
You may use the back of this page to provide additional well site details or well
•\.
repair under#21 remarks section or on the back of this form. es if necessary.
Geothermal Wells having
the same constructionuYidetails. You may also attach additional pag
g.For Geoprobe/DPT or Closed-Loop gR ofwells
construction,only 1 GW 1 is needed. Indicate TOTALNUlvil3S_1-- ---INSTRUCTIONS
drilled ' � (ft.) 24a.For All Wells' Submit this form within 30 days of completion of well
3 00'and 2@I00� construction to the following:
For9 mualwewdepthbedewlandsurface:
multiple wells list all depths if different(example- C� (ft.) DivySion of Water Resources,Information
2769951617 Unit,
of casing: 3 1617 Mail t erRes urces, Raleigh,
I I0. tertic l is ab ve ca below tap the form2769 to the address in 24a
Ifwater level is above casing,use"+" 24b.For Injection Wells: In addition to sending
(m') above,also submit one copy of this form within 30 days of completion of well
11.Borehole diameter: 6
•
rotary construction to the following: Injection Control Program,
12.Well construction method:etc.) Division of Water Resources;Underground NC ion Control
(i.e.auger,rotary,cable,direct push 1636 Mail Service Center,Raleigh,
&Inje'Cen er, In addition 90 1636ng the form to
FOR WATER SUPPLY ONLY: of this form within 30 days of
ZtJ Method of test: air pressure the 24c.For
addreWa era above, also submit one copy health
department di of the county
•
13a.Yield Disinfection
completion of well construction!to the county
granulated chlorine Amount: where constructed
13b.Disinfection type: Revised 2-22-2016
ofEnvironmentalQuality-DiViSinfofWaterReso ies
NorthCazolinaDepartment
corm GW-1 1 •