GW1--06367_Well Construction - GW1_20230927

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
FROM TO DESCRIPTION
Well C tra tor Name ft ft 1
(i.2ZA ft ft ' `
i
NC Well Contractor Certification Number li"f$11;QIITERG?i;SILVG'(£ozfilniti?`cased'ivells);ORJl (iti'aP licalt7e)"z'`5:'"::tiiiii."ir4
Morgan Well&Pump, INC FROM TO DIAMETER . THICIINESS MATERIAL
1 ft C4/_ ft 61/8 m' sdr21 pvc
Company Name• µ IU ,.., t:.:_•;.,.
p y l�♦ :y16;TNNERC9SIPIG:OR 3UisING: eothermal_close po °-<;,; „
1'1.�1 /fir 1 Q�[b 7 �k P�'.:,;;.� T >-:
2.Well Construction Permit#: ''V J" J U �+l7D 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;
17.SCREENr,. .ft :35 ;.::*,.""zi_?,; :,;i+:,`/-, r`'r .= '.?�;=:-'i'F . ;..134:t- 4f'r
Water Supply Well: FROM TO DIAMETER ^SLOT SIZE THICKNESS MATERIAL
*Agricultural 0Municipal/Public fti ft in. .
l Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft ft. in.
*Industrial/Commercial r3Residential Water Supply(shared) a GROUTii�w-',I i' `rl n<<,"•:"":::�`= `x"`•,:-=+';•- - . .
L I Irrigation FROM TO MATERIAL •EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
IliMonitoring Dl Recovery •
ft. ft.
Injection Well: ft ft
*Aquifer Recharge IDGroundwater Remediation .
019 SAND/GRAT1.Ii•P.ACg(if app1iiabler`s;
*Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL . EMPLACEMENT METHOD
*Aquifer Test DStormwater Drainage ft ft
*Experimental Technology OlSubsidence Control ft ft.
Ill Geothermal(Closed Loop) OTracer :201)IntlINGZO;G_CeitacT addifi'inill:s7r"eat3ifAgeessary):,. Z==::i;,-i'-FfT'''t 1VC_'
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
U Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft IS ft Ytd IYT
4.Date Well(s)Completedl l N. I Well ID# 15 ft 55 ft' ;bow,. ('�l'rc
5a.4/�Fi1 ia-lion: SS ft. /15 ft].,VSu-�G r_�s hA
--� 11( J�Oe icy • 115 ft l6 ft kAr mink
Facility/Owner Name Facility ID#(if applicable) ft ft
V �C * ' vi lge iJ G ft. ft. "`•l'. •''16?.,...�5-'i
'�� V�u v 1�Q�_�� ft ft e• '.„,,,g..:,.i V ll,.,
Pb•
sical City,and Zip • D� . •.. ._.,.,..... _ .. _ .-
K/ �Y^e •l a 2I`^RF.MARTCR",-. >'. . .E V ..-r �',iS}: •'y'_V<
;, J
County . Parcel Identification ra
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: "'"'"�"" � .)'"
(if well field,one lat/long is sufficient) 22.C- .: cation:
35 j ‘g4S PS N<b.°I1rl Co W latl?c(2-3
6.Is(are)the well(s);,.Permanent or ©Il Temporary igns: ,,'f ed Well Contractor
By s=wing th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ligNo with 15ANCAC 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed 1 ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1—Dc (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: 35 (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 Infection 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:
(ie.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
i
13a.Yield(gpm) \ ..r Method of test: air pressure . 24c.For Water Supply&Infection Wells: In addition to sending the form to
.�r � the address(es) above, also submit one loopy of this form within 30 days of
13b.Disinfection type: granulated chlorineAmount: O V completion of well construction to the cl unty health department of the county
where constructed. •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016