GW1--07129_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
1.We Contractor Information: :' � '�:'' _
FRROM TO
"1sv4AT `ZONES a-? DESCRIPTION I '
+ a
Well tra tor Name L �'110111111
w iOIZ'INER:if,a,•,7icab"le.`:x�'"�j=i �:ryz;
G fgriauultLgas I 1llNINEss
:7S::UIITEIt°G`ASIl!T DIAMETER NCWellCo WelCtatifiump,uNCmb er FROM TO�
Morgan Well&Pump, ® . .C;OR•�JBiNG _edthe2clds`adloo. -..
FROM . . DIAMETER
2 e Cons FROM
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2. O
Well Construction Permit#: WC tate,Variance,etc.)
well . THICKNESS 112MniiiiiiiiIIIIII .
construction permits�.e, aunty,
3. all applicable ®®:.•..r;•,._. :�;-,;<i- •-•:I ''` I,,-.i;t
IIII
• ,.i 'd:>` i°,Lia�ti.c:-z.�ri. _ ASS.,
3. tell up(check lyWell: use): 1itorsi EEPT - D� SLo==—
FR® T®
IIMEION
Water Supply Well: Dj Municipa1fflh c —
•
Agricultural Water Supply(single) ®�— ^'�`3`'�`
Geothermal(Heating/Cooling g/Cooling Supply) s,.Residential upP © .. r,,;„a is .•.�,..,� :4.;, •-.
rfi ®�Residential Water Supply(shared) �18s'GgOU�' O :':::`=:'`:`'f 'EMPLACEMENT METHOD&AMOUNT
"Irritation
IIth afiOn Commercial FROM TO
D ft. 20 ft. �
�Moniate ®®—
Non-Water Supply Well:
Recovery
1111111111.111111
Monitoring ® i :" t�Y s ' 'z ;, `
Injection Well: iriMMMI EMPLACEMENTMETSOD
10 Groundwater Remcdiation i�;19 SANiitc VEL P.AC7 if a; ica-61e'1;:::.:c: :.o
111111111111
•
"Aquifer StoragRecharge
FRO® T©
"Aquifer Storag Salinity Bother
e and Recovery
immuni
*Aquifer Test II Stormwater Drainage
`..i _-�.:mot,::
�ISubsidence Control ditfoP�sfieetsifs���s�,��l°�-�.rY�;-::- 1:.:.,,:��:
CiIO;G attire att'. size etc.
(�Experimental Technology FROM
DESCRIPTION calor,hardness,soillrock A.e,•
OTracer ZDaD TO
"Geothermal(Chas in Loop) under#21 Remarks)
Geothermal(Heating/Cooling Return) Ili Other(explain � � '�
'C`�Well ID# .y .
4.Date Well(s)Completed: �ii� L_
Sa.Well Location: nSiMi�'�� t'
imillil
) r.
Facility ID#(if applicableimmiii NraMINIMIIIIIIIIIIIIIIII
Eaciliiy/Owner�l a Facility
sical Address,City,and Zip •21?_ _.
Parcel Identification No.(PIR) n
County1111.111111111111
111111111111111111111211
b NOV
fade in de eeslminutes/seconds or decimal degrees: 22.C • cation: 202 1
(d Latitude and longitude Sr
one lat/long is sufficient)
(dwell field P Y1O W -
35
N :.1Da 't.'
Signa f ed Well Contractor G:= �' 'y 0
permanent or Temporary ing , rm,I hereby certify that the well(s)was(were)constructed in accordance
6.Is(are)the weIl(s)>� By s=�T • with 15A NCAC 02C.DI00 or ISANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well:
yes or ffiNo copy of this record has been0 provided to the well owner.
If this is a repair,frll out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form• You may use the back of this page to provittach de
addi tion welll n site details or well
the same construction details. You may
8.For Dion,onll 1 G - Closed-Loop Geothdicate rmal Wells BE of wells
construction only 1 CTW 1 is needed Indicate TOTAL NUMB 5� -INS IRUC TION •
S
e days of completion of well
• �• j (ft) 24a.Forte Submit this form within 30
9.Total-well depth below land surface: 00'and 2Q1003 construction to the following:
For multiple wells list all depths if different(example-3��
(fb) Division of Water Resources,Information Processing Unit,
10.Septic water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
I1 water level is diamcasing,use __ days of completion headdress of well4a
( ) 24b.For Inie� ctiDII wells: of this form within30m to the in 24a
11.Borehole diameter: above,also submit one copy
rotary construction to the following.
12.Well construction method: Injection Control Program,
(ie.auger,rotary,cable,direct push,etc.) Division of Water Resources,UndergroundNC 27699 1636
1636 Mail Service Center,Raleigh,
the form to
FOR WATER SUPPLY WELLS ONLY: p of thus form within 30 days of
Method of test: air pressure 24c.For Water Su I &In ection Wells: In addition to sen g
13a.Yield(gpm) the addresses) above, also subm t one co y health
ey department of the county
completion of well construction to the county
granulated chlorine Amount: where constructed.
•, 13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
term GW-1