GW1-2022-10138_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD (QW-1) For Internal Use Only.
1.Well Contractor Information_
•14:.WATERZONES-C.
F80M TO DEsarT_ION .
Well Contractor Name ft
I
ft ft.
NC Well Contractor Certification Number 15:01r ERG�d6Il�'G•,(ie-r Anlfi=Z ea*05si)bR MV-um(rf IicahIe
Morgan Well&Pump, Inc. FROM TBICKNFSS MATERIAL
/� 14 +1 R $ 61/S/ �' sd21 pvc
Company Name /-- 1 I '-
(� 16"II1NER CAS]T*G OETUBILVG. •eotliermal'cIp'sed l06
2.Well Construction Permit#: FROM To DIAMETER I THE MATERTdT.
List all applicable weII curets uc Yonpermits(i a LUC,Cora*State,Ymiance,eta_f ft ft ''
3.Well Use(check well use): R' ft im
Water Supply Well: 1'z SCREEN'.=:.: _- .`�'.,:•°: - .�::•r::..:•��: _;::•::.:�.::-_. ";-:;•,:.•.::.::
FROM TO DIA IWETFdt SLOT SIZE .:THICKNESS MATERIAL
RAgricultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Snpply) � esidential Water Supply(single) ft
lodustrial/Commercial DResidential Water Supply(shared)
lira ation FROM TO MATERIAL EWLACEMzNT METHOD&AMOUNT
Non-Water Supply Wen' 0 fL 20 fL bentonite pow
•Monitoring Recovery ft ft
Injection Well:
ft ft
Aquifer Recharge �J Groundwater Remediation. _
r Aquifer Storage and Recovery DSalinityBarrier FROM g�/ TO •• PAS MATII2TAL(ife EMP NTMETHOD
Aquifer Test OStormwater Drainage ft ft ingorlf� 4on IO:
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRILLII�TGSOG'(ittacL'additionals eets�firecess" �''` ':-.: `= .` :::` '
1 Geothermal(Heating/Cooling Retum) Other(explain under#21 ) FROM TO DESCRIPT ON(color,hardness,soiUrockippe grant size etc)
�t 6 t
4.Date Well(s)Completed:/6—6-V—Well ID# G fi ft vr-•k ' r
5a Well Location: 3� U
It.
ft O ft (-Z
Facility/Owne ame Facility ID#1(ifa plicable)
'�'� s
Pbyypal�� City,and Zip ft fC
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(3 it one t/long is s�ient)N , , / 22-Certification
. Z3 C�c�o�.el� 6 z�•�
6.Is(are)the well(s) Permanent orI ITemporaly Signature of Certified Well Contractor Date
�� By sig ino this form,I hereby certify that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MI Yes or° I No with 15A NC.4C 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is o repair,ffl out known w0 construction information and eaplafn the nature ofthe copy ofthii record has been provided to the well owner.
repair under 42J remark•section or on the bark 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 NUlvIBER'of wells construction details. You may also attach additional pages if necessary.
drilled I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��' (ft-) 24a. For All Wells: Submit this foim within 30 day5 of completion of well
For multiple wells list all depths ff different(ezmnple-3 cQr 200'and 2@100) construction to the following.
10.Static water level below top of casing: J 6 A) Division of Water Resources,Information Processing Unif,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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: r L` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY'4a .T S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25� Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1� the address(es) 'above, also submit one copy of this font within 30 days Of
13b.Disinfection type:5 C-en01 0.r Amount: 7 G C. completion 0f well construction to the county health department of the county
where constructed.
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Form OW-1 North Carolina Deparhnent ofEnvironmental Quality-Division of WaterResources j Revised 2 22 2016