GW1--03895_Well Construction - GW1_20230609

• . .._PPInt=FomLL,r,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: n •
� -Rl To? A 14:WA"TEEi'7.ONES' ._,;-..;_r.,.. : ._:.:: t.5. -s:
Well Contractor Name FROM TO DESCRIPTION
Na it ft
8 —A ft. ft
NC Well Contractor Certification Number .=- :�- 11-1
154OUTERiCASING:(for mi tt,rasedl¢ells)OR�T.itSFR,'(r£ap 7icable}�r?,�.. .. :�a
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft 30
ft 61/6 m sd21 pvc
Company Name r._>:-.-_ _ _
/JJ n n11 /) i6INNERTGASING�OR=TIIBING.(geothermalclosedloop7 �.. :.
2.Well Construction Permit#: W t I�-O1I-7011- 17 1 511, 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: 17 S.6RF.EN'.t `-:. --�s....`..._�.:: .",:v.�.. a+•s t ,.a;.,._�t '
FROM TO DIAMETER SLOT SIZE n THICKNESS MATERIAL
•
Agricultural U Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) "'Residential Water Supply(single) ft ft. in.
Industrial/Commercial I__.I Residential Water Supply(shared) - -
skGROUT d r- ..... -G .; .
`i Irrigation FROM I TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
' Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring )Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge 0 Groundwater Remediation
r"19r;SANDIGRAVEL=JAG'g'ittiliplicable) -[�.
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
®IAquifer Test DStormwater Drainage ft. • ft.
l Experimental TechnologySubsidence Control ft. ft.
Geothermal •(Closed Loop) Tracer Yi20 RIDEINGT:OG_(att"scli adfii(ionatilifi fifili-e asai �:� `YV
g
i i Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(colloor,hardness,sai]/roek type,grain size,etc.)
�Jy, ID `r'
/0 ft. 46 ft e•CO' di r .
4.Date Well(s)Completed: c-11�L✓ Well # 0 ft (' ft g/BA.c'i pl Y'��
5a.Well Location: C.— ft 7c ft {3 OWEN eocIL
vJC4o/y i?vi3-1 cf5 75 ft 1 b5 ft 6/Ur, 5pir„ic,
Facility/Owner Name Facility ID#(if applicable) ft ft.
•
Z.)GZ Jerv1CY S 1,4 ft ft.
Physical Address,City,and Zip •
ft ft
(�%`' v✓/7a 211 MC Al2'K•l.'...i .., >a .tip :r:-c.'I i. ..t W1:' .=v-
'kJ' -'t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J V N v ) 2OZ3
(if well field,one lat/long
iss sufficient) , • 22.Certification:
S•6o 3/ 7 N 1• I"/,�`) IV 7, w ,/ //6�'' groCaii�,�l d g. ,z,
6.Is(are)the well(s)CIIX Permanent or Temporary -SignatureDAAVVIOG
of Certified Well ontractor 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: E3Yes or iJ'No with 15A NCAC 02C.0100 or 15A 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:' . J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (P (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@100') construction to the following:
10.Static water level below top of casing: `9 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 _(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: — — 163-Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 _. Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ 7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: (._ �4 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016