GW1-2023-02493_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan z4waTEmzorlEs
FROM TO DESCRIPTION
Well Contractor Name G/LD ft.
3572-A D
ft ft.
NC Well Contractor Certification Number
a
15t.;QUTER CAS115G(f0V multi cased'we1Ls)ORLINER`(if a"'licble
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. 1,
3 ft.
Company Name
^► Q' �f t�`16>INNERZ�ASING�ORTUBING`-'`'e6thermal'cla`se3sloo "- :��:'..�.a"'•��L `�.=:`-_;=}�:'
2.Well Construction Permit#: $3 1 V�G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft
Water Supply Well:
PP Y FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
�]Adicultural �=al
llPublic ft. ft. in.
.JiGeothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
!Industlial/Commercial [,Residential Water Supply(shared) - -
h-rigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
I Monitoring ORecovety
Injection Well:
_!Aquifer Recharge Groundwater Remediation :
>j.9sSe111ID7GRA�I:.P�iCIC`"if a`.``licatile' - =. .
NAquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft. ft.
(�Geothermal(Closed Loop) [ITracer '20:;DRUj_M'GL0G`(atticfi=additionalsh69tii:ifn'WAs"
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_!Geothermal(Heating/Cooling Return) 2 Other(explain under#21 Remarks) ft. C
4.Date Well(s)Completed: 6-23 Well ID# ft. `( ft.
ft
Sa.pW�ell Location:
IV ft.
_ I C, ft. ft. ��
Facility/Owner Name Facility ID#(if applicable) PR a
I165 C .6 , a I s�p�lr G ft. ft. ' ��13
a i `
Physical Address,City,and Zip qq ft ft
�o wawi
3S QCo .'2'1:RE11'LRKC:. y 3• u 1t 5 ut -
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.C tificati n:
35-67 0N 12-"6 7 W /0
6.Is(are)the well(s) X!Permanent or [ITemporary Signature of Ce ' d Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E)No with 15A NCAC 02C.0100 or I5A 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: ZOO -(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@I00D construction to the following:
10.Static water level below top of casing: 3.0
(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 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.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) L� Method of test: Ir 24c.For Water Supply&Iniection 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: chlorine Amount: �b2. completion of well construction to the county health department of the county
where constructed.