HomeMy WebLinkAboutGW1-2023-02498_Well Construction - GW1_20230406 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 'xa.-wAa.r:IczortEs-`rg:�-. :,. _ -- ,
FROM TO DESCRIPTION
Well Contractor Name ft. ft. , 1
3572-A 1
ft. ft.
NC Well Contractor Certification Number 15'`GUTER eN8ILL:7G(foraniilfi'qiased'welts)ORZIIYER`(rfap Lcilife) + " :.
Morgan Well& Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. 5.3 ft. 6 i IV in. S11 z i 94c
Company Name �J :16%INNERCASINGOR uSING'(geo m theral cf61111 4 5 6 1i ,,._;.
2 .. .
2.Well Construction Permit#: 1 J1 t I `U I 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.
1tsCREEN., . . r_. _l N i'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Agricultural DMun ipai/Public ft. ft. in.
N Geothermal(Heating/Cooling Supply) -_ esidential Water Supply(single) ft. ft. in.
Xi l_Residential Water Supply(shared) s18GROUT s YY:11 ':-:j,-.i - rP e'-_u
_I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
III Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Nil Aquifer Recharge QGroundwater Remediation _. q"-. _,<:r r i„,.r. :;;>
s'19i;SA1W/GI2'-AVEhPACK"(➢faji li'c'abFej==':t'.= -s>" :._:::w,_X.a....,-..-.. , =
• iiIAquifer Storage and Recovery CISalinity Barrier FROM - TO MATERIAL EMPLACEMENT METHOD
.I Aquifer Test J Stonnwater Drainage ft. ft.
- ii Experimental Technology IDISubsidence Control ft. ft.
*Geothermal(Closed Loop) lDTracer t=201DRIL-TINGLOG(attach;ad-ditiotial`sheets'ifnecessary):
tj Geothermal(Heating/Cooling Return) i_ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4 ft. 30
ft. IDvuw+1 C .
.
4.Date WeIl(s)Completed: 3~i— Well m# S 1 ft Z$ ft' /+rw G+ L1( ,.,
5a.Well Location: 1 ft. it J ft. �7l ""'CC"G
ft. ft.
Tse43 Cnoi .
Facility/Owner Name Facility ID#(if applicable) ft. ft.
(,33S (lPPcv- Pap ler . SrxI100vrv1,1 L ft. ft.
ft. ft r^ o ---
I�
Physical Address,City,and Zip (l�
OI/�Otv1 !Q v � :21 RElNLaRKc t U y fl )
County Parcel Identification No.(PIN) APR J G 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C(si-
6. ficatio in ,in , ,.,-"`71 '- r'C'`.,'':'. i .t
i.r.,
35 5662 N TO, 3716 w3 m.T?3
Is(are)the wells) x!permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [jYes or XI 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 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:' dL SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 4) (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 1@100) construction to the following:
10.Static water level below top of casing: I (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) 20 Method of test: Air 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: chlorine Amount: completion of well construction to the county health department of the county
where constructed.