GW1--07130_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
1.W Contractor Information: ; NE ,-y ' 12•�. ;st;• ._ -' - `,':' - .
e ?14w'WATER7A S h
FROM TO DESCRIPTION
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WellC a tor Name t , .I,
if;a,,licab`l`e..4
MIIIIIIIIIIIIIIIIIII
:r15aOUTERCASIP1.G'fosmulh,cased-well's',OR S
NC MWellCo Well Certifiump,uN FRO® TO grisoTiAmEE .
Morga
n &Pump, INC 11® rmik.Flgsew: :f: ;.•,•-„{ �.
ia1G::INIVEILGAS�G�ORTUBIN��RO. •rgIClINESS
Companycons . /> , �� FRO® TO DIAMETER
Well Construction Permit#: ✓1UU �I• State,Variance,etc.)
Lr.Wellst all ennits(i.e.UIC,County, 111153111111311111111111111111111111.11111111
,.111 _•-.--1111 'G-L.=._.
applicable well construction p .__
well Use(check use): ,17SCREEDI':,�? ta:�'.`�,� �w`:=`-;•-`:�,OTSIZE
3. telluply FROM
THICKNESS 110MM11.1
Water Supply Well: �j Munioipa]/Public
L.Agricultural Water Supply(single) r—
Cooling Supply) 'i .RResidential W PPl �) ® : :�K.:. •.,•_,,_, ` y
*Geothermal(Heating/Cooling is - wc..t>__M.. r-
®j lResidential Water Supply(shared) ? $x'GROU }"O ::"Y` PLACEMENT METHOD&AMOUNT
Uilrri: tiiaUCommercial FROM TO !s'''s�y"'
0 it 20 ft. �
iIr Monitoring
on ®®—
Non-Water Supply Well:
Recovery
IIIIIIIIIIIIIIII
njectitoring ®— - _< v:i=:z^:' !.s.: ?x,�,y:
Injection Well: ...:.. . ._ "
IINIIIIIIIIIIIIII
DGIoundwater Remed1at10n �:S�IGgA�y�ii.E9CK:�tf=�•;��ble'I•;'`•'�'-:�5: ggLACEtvIENr METHOD
*Aquifer Recharge a FROM T®
_j Salinity Barrier
�iAquiferStorageandRecovery �StormwaterDrainage
Igmum
Experi entaTest ®I._. �' " "
*Experimental Technology Subsidence Control slie-bA if nec 3-sa •::t0'f t-F.':,size eta)
�TIseeI =.aFRO TO O,G-altachDES ON color,hardness,soil/rock A.e,.
FROM
*Geothermal(ClasenClosed Loop)Cof b ft MOWN Ir
eaten Cooling Rearm) Other(explain under#21 Remarks)
L� DaeWeGeothermal(H gl
��� �i�f -Well ID#
4.Date Well(s)Completed: `''�' , ft• �'��w ••, a-
ft
Sa.Well Location: \ - � .w ►�,. i
�./ 1 li�triY U. . f
Facility ID#(if applicable)
Facility/Owner Name
Physical Address,City,and Zip al bar 2P RE1Ya _='"
out.•ly .i ►
PazcelIdentificationNo.(PIN)
County degrees: In:>„-��^ ;1 ?�•.,-� •':� :`� i;!':i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degr 22.0 cation:
i;';
(if well field,one/la/t/ylong is sufficient) 1 0 D-3
3-5 1 w�7� 1 W Date
N
Signa f C9 �ified Well Contractor
permanent or �Tempor
Byary
s titrrrt,I hereby certzfy that the well(s)was(were)constructed in accordance
6.Is(are)the well(s)* = 'rig
with 15ANCAC 02C or ISA 02C.0200 Well Construction Standards and that a
Yes or No copy of this record has.0100 provided NCAC to the well owner.
7.Is thisa a repair to an existing well: explain the nature of the
If this is a repair,fill out lean well construction information and P 23.Site diagram or additional well details:
You may use the back of this page to provide additional wfellll site
details or well
repair under#21 remarks section or on the back of this form•
the same construction details. You may also attach additional pages 8.For GeoprobelDPT or Closed-Loop Geothermal Wells havingof wells
f construction,only 1 GW-1 is needed. Indicate TOTAL NUMB S� TAL INSTRUCTIONS
drilled t of completion of well
9.
�{/'�5 _----X ) 24a.Ford: Submit this form within 30 days P
For multiplealwew deptht belowd land surface:y 3r 00,and 2@100) construction to the following:
wells list all depths if different(example- (��
`7� Information processing Unit,
(ft.) Division of Water Resources,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
\.
If water B level is acasing use"+" ,to completion of 24a
(�) 24b.For Ini R'ells' of soform sendingwithin 30 days� theP address in 24a
11.Borehole diameter: 6 above, also submit one copy
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 Tenter,Raleigh,NC 27699-1636
the form to
FOR WATER SUPPLY WELLS ONLY: of this form within 30 days of
Method of test: air pressure 24e.For Water b 1 ls Injection Wells: In addition to sending
the addressete above, also submit one copy health department of the county
1i .Yield 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
Donn GW-1