GW1--04837_Well Construction - GW1_20230728

Pnnt'Form_:
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.We Contractor Information:
• 14;_SVATER-ZONES5. , ,.. . .. ,.1 • •
Well C ira tor Name FROM TO DESCRIPTION
�� • ft ft
�. ft ft i
NC Well Contractor Certification Number 0.5:',O,ipTER.GASING•(foi multi=rasedwell's)OR7RNEIt(ifsp liable)T.
Morgan Well & Pump, INC FROM TO DIAMETER ' THICKNESS MATERIAL
1 ft ki ft. 61/8 m sdr21 pvc
Company Name , \ ti,=a r . _
�1�i .��16 IKNERCi1SING'OkTUG;'{g'e BINoth'ermal'closea.loop) . -r_:-_ _.-
2.Well Construction Permit#: `VV--�7�+'J�Dr • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.NC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: �<17 SCREEI�i:',.�"'>::.�_ :-<�rwr.,;._.�s>;L=._�:.r'1:__- .:.::..._:;�'`;z%;' -.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1:]Agricultural DMunicipal/Public ft. ft in. .
t_I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in._i Industrial/Commercial �IResidential Water Supply(shared) ;i1B;:GROITI'::::i �.> 'a'=°CC r
-. .'7;�''� .- - - -
l Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring D1 Recovery ft. ft
Injection Well: • ft ft.
Aquifer Recharge Groundwater Remediation
d19 SAND/GRAXEL PACK(if;applicable); `.. ...,_ Ya.i :r`;i .='' r`;`:"
Aquifer Storage and Recovery �J Salinity Barrier FROM TO MATERIAL ,Y IEMPLACEMENTMETHOD
(_Aquifer Test �IStonnwater Drainage • it ft.
L Experimental Technology _ Ell Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer `20f Ii 1NG1OG(attsckadditional'shhe'etsif n`ecesssaiy)a�`s�=: i%= _ '`:^e=�•_.
Geothermal(Heating/Cooling Return) i�Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
ft i t' ft. lf� � _I
j 17 J 1 �1"t"
4.Date Well(s)Completed:L7/• dl I Well ID# S ft (46.
L ft �O'lt^ ?�`,
5a.'Well Location: {{ ( Lill© ft 5 �`r. . Tail
' OLIA,4 / 5� ft /A' ft
Facility/Owner Name �~1T^`7�', . Facility ID#(if applicable) 66 ft JC.) ft J tiracdp": ("41. v
.(V3 1 V V WAs'Y tt iyel MC,23 i 0 ft. 66
6 ft �1 •Li.Ae,
Phy'cal Address,City,and Zip ft. 4�J ft k]l J lJ L 2 8 20?3
2I;-RE11Ii+iRICS: `:"
County LilIl� � ^: Parcel Identification No.(PIN) .,,J`-:: .~ �.- V n+_ -`
DVA.et.ji s`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ' cation:
35,4c;(1 . N %.50417 W 2 t t�"S
Signailiff ified Well Contractor6.Is(are)the well(s)*JPermanent or i_r Temporary
Signal( ;'f ified Well Dot
By s: mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or *No with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
' If this is a repair,fill out blown 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:'"[b:✓,� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp7le-3@200'and 2(4)100) construction to the following:
10.Static water level below top of casing: 6 (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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C >' 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
granulated chlorine 4 10 6z completion of well construction to the county health department of the county
13b.Disinfection type: Amount: {
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016