GW1--07128_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD (GW'1
For Internal Use Only:
1.We Con Information: ;'�=.:ri:,ii-.-• I- - ,,,.:..-
Contractor Inform ;1gµlvpxER. NES;s;n` ia~
FROM TO DESCRIPTION
Well C tra tor Name Illiffai-?MiltaillimulLalgo....111111111111111111. .
enim
Dells;OI7 tf l r. r .,
:<15'ODTERCe'SIJ� IAMETER I 1H1nagirsu� MATERIAL
M Well Contractor CertificationNu INCFROM T
Morgan Well&Pump, N • ® ruBuv ;lisoaeaoo � ys; ';:.t .;
1"6':INVERG9$71�IGr GR 1111111111111111111111 ,
CompanyN.
. Cons Ir FROM TO D�
Li Well Construction c Permit#: UIC,County,State,Variance,etc.)
3. all applicablewell construction permits(i.e. ®® ..:.. �. •,: ,.
•
Water
Supply
y Well:
use): IIIIIOIIIIINIIINIIIIIII
FR:SCBEEhTO��'---^='•D S,0=�—
FROM
Water Supply WeII: DM„nicipa11 1 0 —
MIN
Lf tial W Supplys �S—`'-- ,,,:�•,-r
AgriculturalII stet (single) � .,...,.,.: ;��� . :;,:•:. ..=
•
eating/Cooling Supply) *Residential © <.:.�,, :,1", :.t�..2Z..>- . :._. .
Geothermal(x .1:-•.�.^ .�' gMpLACEMENTMETHOD 4,AMOUNT
Milndustria1/Commercia . Residential Water Supply(shared)Mari:atioa FRO MOpT}To. _:': `y s':`'.
0 ft. 20 ft
Mil
Non-Water Supply Well:*Monitoring DRecovery INEIIIIIIMIIIIIIIIIIIIIIIIIIIIIIII
®®— :-:�;-`c,Vie, 1`J `i c•`:i
Injection Well: EMPLACEMENT-- EzRoD
*Aquifer �GroundwaterRemediation v;19,'.SANDIt iVEI+P rfa, livable =? :'O ~;
II Aquifer Test
Salinity Barrier1111111111111
FROM T©*Aquifer Storage and Recovery �Stormwater DrainageIIIIIIIII INIIIIIIIGIIIIIIIIIIIIIIIIIIIIIIIIIII •
DI Subsidence Control , etc.)
IExperimental Technology- r.�ROM TOpG`attiicliadaiRIPTIh colon
Tracero� TO DgSCRIPTION color,hardness,soil/rock A.v '
�i Geothermal(Closed Loop) 1�/ ft. a 40 00
Return) ilOther(explainunder#21Remarks) a'��
*Geothermal(Heating/Cooling �� '*aif • •
ItJ llID# l
4.Date Well(s)Completed: O L `��� •
Well Locatio rr Cie dL .�Aiimmip t'"
vV Facility ID#(if applicable) �®
Facility/Owner Name
Physical Adokss,City,and Zip CS
t _____C r ` - -' _
County 22icatioNo (PIN)
'('U � � 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
22.C cation:
eis sufficient) �,.�
(ifwellfi 1 onelat/long N5S0 O �— IZ_ 2-_----------.--^; ,D ,.ed Well ConctorII at:
6.Is(are)the well(s)*
Permanent or DTemporary B,s mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair outto knnown
existingwell ons
yes or *No copy 5 this record has provided to the well owner.
well:
23.Site diagram or additional well details:
• If this is a repair,fill known construction information and explain the nature of the
repair under#21 remark~section or on the back of this form 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 drilled:' only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
(� SUl_A_a'TTAL 7xSTItUCTIONS
e `V
—1 (ft.) 24a Forte �tthis form within 30 days of completion of well
F Total well depth below land surface: 0•and 2Q1000 construction to the following:
For multiple wells list all depths if different(example-3(�
(ft.) Division of Water Resources,Information Processing Unit,
of casing: NC 27699-1617
1617 Mail Service Center,Raleigh,
10.Static water level below top the form to the address in 24a
Ifwater level is above casing use"+,
%
(�) 24b.For Infection Wells: In addition to sending
11.Borehole diameter: • above, also submit one copy of this form within 30 days of completion of well
rotary construction to the following:
12.Well construction method: Injection Control Program,
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground
1636 Mail Service Center,l Raleigh,NC 27699-1636
the form to
FOR WATER SUPPLY WELLS ONLY: p 0 f this form withvn 30 daYs of
/LfL Method of test: air pressure 24c.For Water Su 1 &Injection Wells: In addition to sending
the addresses) above, also submit one co Y healthof
mwrti of the county
13a.Yieln Disinfection
completion of well construction to the countydepartment
granulated chlorine Amount: where constructed.
• 13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Wer
er Resources
dorm GW-1