GW1-2022-08481_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
1 V �'Aa •14:.WATkR ZO1qE.S
FROM TO DESCRIPTION
Well ConttactorName - ft ft
3s7Z -A � � ft ft �
NC Well Contractor Ceriification Number 15.OUP ER G�ASTNG.(foc mnlfi-e*ed wells bR EMIKO R it - ticahle'v:::`.. : '•
Morgan Well &Pump, Inc. FROM TO' DIAMETER TRICTOMS MATERIAI
+t ft- /06 ft 61/al I ia, sdr11 pvc
Company Name e !` 1t%aII�I2 CASING OIt•T[IBIIIG. •euthermal cloked-lob': '
2.Well Construction Permit#: c �1 O 9V FROM TO DIAMETER TMaGMSS MATERIAL
List all applicable well construction permits(Le UIC,Carty,State,Variance,etc-r M ft 1a
ft ft in.
3.Well Use(check well use):
. 17.�SCI2EENN',:.:.: 'r• :• ,;,•. _ :.•-.:• l.i-- .;,:•.:.'=;;.. t.- ..-; :
Water Supply Well: FROM I TO DIAMETER SLOT SIZE r TFHCKTMS MATERIAL
Agricultural !fit crpaUPublic ft ft
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft �•
I IndusYria7]Commercial Residential Water Supply(shared) —
�•8:-GROAT•-�•. .. _•..
'Irrigation FROM I TO I MATERIAL E aIjLCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- bentonite poured
Monitoring Recovery ft ft
Injection Well: M ft
_Aquifer Recharge [3Groundwater Remediaiion
:.19:S, ND/GRAVEL-PAQK if a'iiekbre -.•:_.•
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
gGeothermal
Aquifer Test 0StormwaterDrainage ft ftExperimental Technology Subsidence Control ft, ft•
Geothermal(Closed Loop) OTracer :28.DRZnNGLOG'(ktti' additiorisl sheetTtf aeces-s--'.'FROM TO DESCRIPTION(colorhardness,soil/rock mi ,etc.)
(Heating/Cooling Return) i Other(explain under#21 Remarks)
4.Date Well(s)Completed:/I �-ZI Well ID# �� ft 7,7 fL 1�
X11 Location:
6 ft � C4mmf '
n ft ft yea
Facility/Owner Name Facili M4 if applicable) ft ft
l0 __ Sa G
ft SIP 0ILL
Physi Address,City,an ip ft ft r%s'.- 1)IS'°
A goo/ :'.�
��I 'ZL'RT,'MdRKR'_�i. _ `a- _ _ :.'-`-1F11�•+L-ttost:'':.,::_s l.:y. '
County Parcel Identification No.(PIN)
5b.Latitude and long tude iu degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C lion: .. ..
5 577 -N Q'yg qy Q'' a " `M
6.Is(are)the wells) Permanent or 13Temporary Sim of C ' Well Contractor Date
By signing this orm,1 herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or 81N. with 15A NCAC 02C.0100 or 1SA NCAC 01C-.0200 Ylrell Constwction Standmdr and that a
Ifthis is a repair-,frII out known well construction information and explain the natw-e ofthe copy of this record has been provided to the well owner.
repair under 421 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 NUNIBER'of wells construction details. You may also attach additional pages if necessary.
drilled: w SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZOO (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells[1st all depths tf different(example-3@200'and 2@100D construction to the following.
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If woier level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this,form within 30 days of completion of well
12.Well construction method: '-0"Ir(✓` - construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSeONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a-Yield(gpm) O 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 Amount: r o aZ completion of well construction to the county health department of the county
where constructed_
k
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2 22 2016