GW1--06381_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.We Contractor Information: 1'• �:'. 6- •- ' :,�:~ ..
14:WATDR7ANES rt.:itiw-
FROM TO
DESCRIPTION r
Well C tra tor Name M Sb ft. li♦
T�`lER zf
�_ ;¢1':lical'ile:I i�es'{"=�'ir";>'jtii,
:'15's":OIITER CASING form per ells ARSS iffmaMMONINE
NC Well Contactor CertiScationNumber FRO® TOETER .
``T�O 6 vs
m,I�
Morgan Well&Pump,INC u� �o6�zsu• -.;;:i;1��'e:i„��t�•�=�:=;�_
nsom
y� 16;.71QNERr'o1NC%OR •TER ermal
Company Name , ')A. '1/4t 6 15 FRO®®�
Construction Permit#: '� (,J`+
2.Well Cocable C County,State,Variance,etc)
3. iiiiicaNgs mum .
all applicable well construction permits(.e , 1 .
-
11110111111111111112111111111111111111111111
I,. . -V w�;L�r-,ti :',=':,67;,<,.,!:i�s_:., :11:', S
3. tell Supply(check Well: use): 17::SCRFEN DIAMETER "S,o===
721.1
Water Well: �j lvlunicipa]lPublic
arsOM
T®®
�I Agricultural (single) ®�
Geothermal(Heating/Cooling Supply) I -iResidential Water Supply( P�) ®� m : . ;r ..: ;,�.. ;`<::;:,:. .
.11111111111111111
Residential Water Supply(shared) :1gt•GgOUti'TO •" » •''' EMPLACEMENT METHOD&AMOUNT
iIIndustrial/Commercial FROM TO
0 ft. 20 ft
ihri:•lion ®�
Non-Water Supply Well:
DIIIIIIIIIIIIIIIIIII
RecoveryIMOn1Y0ring ®®�F •,� :i Y:'r''": S sa:
Injection Well: IIIIIIIIIIIIIIIIIII
.ura:i.:� =�F'
*Aquifer Recharge DGroundwaterRemedtation v197$ANDIGRAP 3iie't' -':�`f EMPLACEMENT METHOD
Salinity Barrier
FROM TO
iAquiferStorageandRecovery �StormwaterDrainage
INI Experi Test �- 1 -: ^',
®ISubsidence Control -•-- •e""`'�- :tP` 'a x°�``"`
Experimental Technology l t D I.O•G"attaefrD tiOR slieetsi-if-a hardness,soivrnck 4.e,r size,etc.
*Geothermal(Closed Loop)
Tracer FROM TO
IN Geothermal(Heating/Cooling Return) *Other(explain under#21 Remarks) IMILligas L
11-11M1111111111111111111
4.Date Well(s)Completed -Well DO MI®MI
ft
5a.Well Location: &ft• [/ tIv _..►
,w A
Facility ID#(if applicable) b ft .J •e r, 1� (,
Facility/Owner Name kdo k +G e b ft•7511 Physi Ad ss,Cityk,and Zip C, 1111611111111miouniiiiiiimen
1? •'
� �
county2�23 parcel Identification No.(PIN)
�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n r T O r
(if well field one laUlong is sufficient) 22.C ' cation: U 1
�v \ .re,� b' E>3
+� �J� ` gigaa f ied Well Contractor ric;�iSg%
permanent or Temporary fh +•ny,I hereby terrify' that the well(s)was(were)constructed in accordance
6.Is(are)the well(s)t®I By s mg
with ISANCAC .010002C or ISA NCAC 02C.0200 Well Construction Standards and that a
well: fires or No with
co o5 this record has provided to the well owner.
7.Isi thisia a repair outt knnown
existingwell lain the nature of the
If this is a repair,fill known well construction information and explain 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this farm• 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.
SUBMITTAL INSTRUCTIONS
drilled:' '��� (ft.) 24a.Forte B�� ��t� fog within 30 days of completion of well
ll wow llspth bole t lafd surface: 00 construction to the following:
For multiple wells list all depths if different(example-�D�d 2°� � (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service]Center,Raleigh,NC 27699-1617
\-
1 the form to the address in 24a
If water level is above casing,use"+" of completion of 24a
(. 24b.For Iniection Wells: In addition to sending
11.Borehole diameter: 6 m) above,also submit one copy of]this form within 30 daysp
ll
rOtal y construction to the following.
12.Well construction method: Injection Control Program,
• (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground C 27699-1636
1636 Mail Service Center,Raleigh,
FOR WATER SUPPLS ONLY: the form to
Method of test: air pressure the addre s(es)r above, also submit one copy of this forms within 30 days of
13a.Yield Disinfection11._ i3 O`L completion of well constmchon to the county health department of the county
granulated chlorine Amount: where constructed. i
13b. type:
North Carolina Department of Environmental Quality-Division of Water ResourcesI
Revised 2-22-2016
corm GW-1 pl
I