GW1--06363_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only: ti
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1.We Contractor Informs ;,14FVATER;ZONES b ;'±a iu -_ y
TO DESCRIPTION
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30 IVI IT
Wen tin tor Name
11111131111113
nitLcuetLivells Q1t7S]NER if s:li'c.;ati7e `;I=:i F n-;nS;
tx`'15`.01:11E MMING fos�a Dl ' TffiCKNFSs wimmMATERIAL
NC Well Contractor Cartif Pump,
u INCFROM To ® -
Morgan Well&Pump, N ilt,117. lose loo• `.
` ,r1G95IKG:OATAMEI � lEss
Company.WllCons • �A�K�y �� 1, b , FROM T®®-
Kjyv v
imoTERIAL .
L,'weIl Consble well cons r construction
ot#: WC,Co '.nState,Variance,etc)
3.Li all applicable well construcri: permits�•e 111111111111131111111611111111111111111111111;, �'•y`-:tz
3.Well Use(check well use): • >17::SCREI:-^• DIAMETER SLOT Water Supplyl Well: 0Municipa1/Publio
FROIVI® T®®
THICKNESS -11101111
i1 Agricultural Residential Water Supply(single) 1.311100115101.0111111111.11111111
®� ,*'. • '1111•t.
(Heating/Cooling Supply) ,.,';'; 4. ::.,•:.:tsv.,...::. __ .4•)•
Geothermal(Heatm -•`- ..-,• '��','''� EMPLACEMENT METHOD&AMOIINT
�IResidential Water Supply(shared) ?1ROM _TO .'= ��
U Tndustria]/Commercial • FROM TO '•
0 ft 20 ft
�Ilni:atori ®®®
EMI
Non-Water Supply Well: DRecovery
IIIIIIIIIIIIIIIIIIIII
*Monitoring ing 11111111111113111111111111111
ntH�; ., x-
Injection Well: i;
�GroundwaterRemediation '19$-BANI)lG1i�AV�%P�GK�•� 1i�3i1e�'"�' �''` EMPLACEMENT METHOD
*Aquifer Recharge FROM TO
*Aquifer Stooge and Recovery
J SalinityBarriei
q DStormwater Drainage
*Aquifer Test , ,::
�lSubsidence Control G•a��:ad3ifionaTs7ieets-ifneces"sa`.�)���'''���'-' `,,size,tom'``='
a Experimental Technology g. p Dj7 GZO; DEseRIPlzo color,hardness,soil/rock I.e =
Tracer FROM TO
�IGeothemial(Closed Loop) 20 ft. � �,
Cooling Return) MD Other(explain under#21 Remarks)
Geothermal(Heating) '2�ft T., ft• 11"
4.Date Well(s)Completed:
ell ID# t4.
oSa,yt'^ll Location: ®�
f applicable)Facility ID#(�z PP
Facility/Owner Name lMlgllraIIIIIIIIIIIIIII
A 111111311111121
,/ 1/
and Zip 111111311111111
l 21t 1i31`:: �:a.>;:'.::: . ',
Physical Address,Crty, P
L.
Parcel Identification No.(P)N)
County 1' G�`y`';:=%''~''L�
degrees/minutes/seconds or decimal degrees: ^,
fade in degr 22.C ' cation: 1 !''� ��
5b.well
field,
de and longitude
• (ifwell field,one lat/long is sufficient) � t✓���•Q W �
/ �� (fl Date
�—•-00 �� —N ns f ed Well Contractor t BySi a
permanent or Di Temporary By s mg th e I hereby certrfy that the well(s)was(were)constructed in accordance
6.Is(are)the well(s)a� with 15A NCAC 02C.0100 or ISANCAC.'02C.0200 Well Construction Standards and that a
7.
If
Yes or +No copy of this record has been provided to the well owner.
Is this a repair to an existingll well: lain the nature of the
•
If this is a repair,fill out known well construction information and explain
23.Site diagram or additiomrl'well details:
You may use the back of this page to provide additional well site details or well
repair under#21 remarks section or on the back of this form. having also attach additional pages if necessary.
the same construction details. You may I,
S.For Geopo �Gw 1 isd Closed
-Loop
oIndiic to TOTAL Geothermal NUMBER of wells
constructionSUBMITTAL INSTRUCTIONS
��� 30 days of completion of well
(ft-) 24a.Forte Wells: Submit this form within
1 For9 multiple wells
depth belowd land surface:example-3@200'and 2@100`) construction to the following:
� multiple wells list all depths if di�'erent( (�)
Division of Water Resources,Information processing Unit,
C�-� Mail t e Res Center,c , Raleigh, 27699-1617l
10.Static water level below top of casing: • the form to the address in 24a
• I1 water level is diameter:
casing:use"+" of completiondres of 24 a
(in.) 24b.b Far Iris ti it one co of this forms within 30 days
; i1.Borehole diameter: 6above,also submit one copy
rotary construction to the following:
Injection il
Program,
12.We11 construction method:etc. NC Control636
• (La auger,rotary,cable,direct push )' Division of Water Resources,Underground
•
1636 Mail Service Center,Raleigh,
S ONLY: the form to
FOR WATER SUPPLY WELL p of this form within 30 days of
Method •
of test: air Pressure the.For Waters ovel also submit oneelco y addition to sen g
7ZAthe addresses) health department of the county
13a.yield echo _OZ completion of well construction to the county
granulated chlorine Amount where constructed.
•
•• 13b.Disinfection type: i Revised 2-22-2016
No Carolina Department of Environmental Quality-Division of Water Resources
cow GW-1
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