GW1--06444_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ' •
1.Well Contractor Information: .
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145WATEll;ZONES:.; S';'';::
Well ontract r me FROM TO • DESCRIPTION I
• SAD'? I_LS ft /1-Z6 ft. 5It.ri, 1
W36 ft r'35 ft p>�:
NC Well Contractor Certification Number - - • qq P•• 'r,:-• • _. . .
•Morgan Well &Pump, INC • • FROM TO DIAMETER THICKNESS MATERIAL -
0 ft• tD ft •6118 in' sdr-21 PVC
Company Name i6.I1VPIER:CASING.OR E[IBING;(geothermal closed-loo "'
2.Well Construction Permit#: VJW p� O'V �.e 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: IT::SCI21tiE�N•<:•.':;:s•::;�. �::%;kr>.•:°�.'�:::..:••..:.:::>r•<,':::;.:::.,: >:<::.,-.�• �•;•.'.i ,- '�: :: :a:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultdral 0Municipal/Public ft ft. in.
Q Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft ft. in. •
0Industrial/Commercial 0 Residential Water Supply(shared) :.IS'GROUT.:ct...:.":..';'':'. ?. :.:.•'. . . -::. .`::;:(,_:•�-::: ;'•;'`-)..c;%:, ,�=
fp� i
lnigation FROM TO MATERIAL•..,, •tEMPIACEMEiN1IMEt''HOD&AMOUNT '..' .'
Non-Water Supply Well: o ft 20 ft bentonite poured rr''
El Monitoring Recovery . ft. ft. N O V j. 1 2 U 21
Injection Well: ft. •
• ft.
Aquifer Recharge GioundwaterRemediation :`,: "'�� ^�"�';ry,�nY
.19:SANDIGRAVEL'PACK(ifiipplicable) :..�..: ::..};...`.,•.•.:'t;.�3,,,;:,.�Ez.�:;:K.' ..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODMETHODAquifer Test 0 Stormwater Drainage ft ft.
Experimental Technology )Subsidence Control ft ft.
Geothermal(Closed Loop) [Tracer •2o:.DIFIELINGLOC(attaeb-itdditioriai'sHe&ts'ifnicescary)"::'a•::;::::;-^,'z;::'.a'>:;;>-::;''
I Geothermal(Heating/Cooling Return) f1Other(explain under#21 Remarks)
il,FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
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4.Date Wells)Completed: L �� Well ID# Zo R' 35. ft .L Ytxy j� awl.-
5a.W Location: 2 5 ft 45 ft. t)i e w v, C� .
pi koc, t.kaw►eS 4s 4L5 ' Cep g ra..hi .
Facility/Owner Name Facility lD#(if applicable)
!1.1. 54lzkotiv-m 146 ft ft.
Physical Address,City,and Zip ft ft. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22. >...:1 cation:
35. �7 7g N Sib.0 298i5 W �/ 91.115���
6.Is(are)the well(s)JPermanent or l.1 Temporary Sig 1S7 rtified W C or Da
By signing t is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or rj1 No with ISA NCAC 02C.0100 or ISA 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 ofthis record has been provided to the well owner. •
• repair under#21 remarks section or on the back of this fonn.
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.
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drilled:' / / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L gLO'J (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@100) cohstruction to the following:
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 _ (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
(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
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13a.Yield(gpm) 02-0 Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 30Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016