GW1--07133_Well Construction - GW1_20231101

WELL CONST1aUCTIoN RECORD (GW-11
For Internal Use Only:
1.We Contractor Information: A .ZQIiE3>=.y :$''' "� "
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DESCRIPTION I
r
Well tra tor Name ■'igillia :
s`=i-I"wells ARZ `iER
t if`a:'�lical'Ig.��-se4 F=Fr.�16�::•±.
':e15ioIIT tlX.: G fosififai ' TffiCKNESS
M Well Contactor CertificationNu INCROM r TO mAME' in'lI 6118 . • • -•
Morgan Well&Pump, -"`
;16:I1QIQER.Cr9SIL1Ci;OR�INCT :eotli`eimapclose�_lo
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DIAMETER imilimilim.RIAL
Company.WllCons . FROM TO
2,Well Construction Permit#: State,Variance,etc.)
applicable well construction permits(r a Tn ounty, ®® 5..., . . aw"' i ..''�
List all ;. :.°>• ':.. •.
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3.Well Use(check well use): •
>17t:$CREEhL.=�'-r--• "'-"/mom iimarr DIAMETER`"sx.o� -
Water Supply Well: �j Municipalt'Public
II Agricultural L�j Water Supply(single) <,_n4;: y^ .;a
•Geothermal(comer g/Cooling Supply) *Residential W PP -.: - �„: ."rr, •_s:... •;,1::_,:=:,:.
�.- �-�- - =�i'"•:-�'" TROD&AMOUNT
IIIIIIMINIIIMIIIIIIIII
DResidential Water Supply•(shazed) '1S?'GRO71T'= .':C=' EMPLACEMENTME
i lrri:triaUCommercial FROM TO
0 it. 2p ft
Non-Water Supply Well:
*Monitoring onitoring ® ;; N ems,: ...
Injection Well: EMPLACE1vIENTMETa'
�GroundwaterRemediation r�.S�(�,1r�;I'i.pAGK rf:�,7ira"T'le .•;,-: .,.��•.�..�-�-
*Aquifer Recharge a FRo® T®
�,SalinityBarrier
oD
�tAquifer5tomgeandRecovery �StormwatetDrainage
•iExperi ExTeperimental
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©1Tracerence Control size,etc.
Experimental Technology G'attach sESCR naLs7N col r,hardness,
ard ess,soillr ck'I.e,I.•'k i
GZ;O;
20DRII�f1!1 D�CRIPTION color,hardness,soillroek I.e,� '
FROM
*Geothermal(Closed Loop) �ITracer To � •
Geothermal(H eatin Cooling Return) **Other(explain under#21 Remarks) b ft
I:) ID#
4.Date Well(s)Completed: Well ��" ��
5a.Well Location: - '
�±w wi_�+ VOCAL
Facility-'(if applicable) Mill
Fan' caner a 11113® s3:
Address,City,and Zip n 2r _ �;'?;f:`- _*
PhysicalA IIIIIIIIIIIEMIIIIMIIIIIIIIIIIIIIIIIIIIIIII
�'_,��/ 1 _'1-rrr.r ■ 1
Parcel ldentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.0 cation: A n 1/ t
(if well field one lot/long is sufficient) I V l 1 V - 20
N�h �� W
11:14a423 .
Sigoa f 'fied Well Contractor �-
p� era or rn,I hereby certhfy that the welt(s)°'wasl(ilereLca t ted in accordance
6.Is(are)thewell(s)kPermanent or °T p Byso mg
j� with ISAIJCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
well: ��r� or �"`o copy of this record has been provided tothe well owner.
7.Is this a repair to an well explain the nature of the
If this is a repair,fill out known well construction information and 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
repair under r remarks section or on the back of this farm• also,attach additional pages if necessary.
Geothermal Wells having the same construction details. You may
8.For Dion,only 1 GT or Closed-Loop ofwells
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBERSUBMITTAL INSTRUCTIONS
drilled., of completion of well
(ft.) 24a.Forte s: Submit this form within 30 days P
9.Total well depth below land surface:�I 00'and 2@I00) construction to the following:
For multiple wells list all depths if difj (ft.)
-��11L4lJDivision of Water Resources,Information CP2769951617 ing m�
1617 Mail Service,Center,Raleigh,
If Static water level below use top of casing: the form to the address in 24a
Ifwater level is above casing "+'
6 (�) 24b.For]nie�n RteIls° 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: l
•
12,Well construction method: Injection Control Program,
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,i Underground
1636 Mail Service)Center,Raleigh,NC 27699-1636
the fora)to
FOR WATER SUPPLYWELLS ONLY: P of this form within 30 days of
Method of test: air pressure 24c.For Water Su 1 &Injection Wells: In addition to sending
13a.Yield(gpm) the address(es) above, also submit one copy
` completion of well construction to the county health department of the county
granulated chlorine Amount: V'1 M. where constructed.
• 13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resourlces
?o:. GW-1