GW1--07135_Well Construction - GW1_20231101

•
WELL CONSTgUCTION RE
CORD (GW-1 For Internal Use Only:
1.We Contractor Information: iawAr µme.
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FRO
1 DESCRIPTION'
f
Wel1C tra tor Name v TO
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=it
case tfiell
:ej siiou1 R WING:fo;em DIAMETER THICKNESS
M Well Contractor CertiS c rap,u INCFROM TO
an Well&Pump. N OM TO ft. isi k :b°;::r II
Morgan 0ASING:OR'F IN�T
;ld R' TO DIAMETER ' THICKNESS
Company.WllCons , Obf in. -
2•Well Construction Permit#: t C,County,State,Variance,etc.)
ist all a permits(i.e. `,. -. . ..--..-•.:..,i:".utisrr•_,+,.®
L applicable well construction p ®® ::--1. -='•- '
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"17:SCREE2Ii�' _1= 6THICKNESS 3,Well Use(check well use): DIAMETER
� SLOT -- .
FR® T®
Water Supply Well: �Municipa]/Public
IX Agricultural *Residential Water Supply(single) --'•':,�`;'eII
eating/Cooling Supply) Resi © ..t::::,.::. �';. •
Geothermal(Heating/Cooling �':�-:•:
EMPLACEMENT METHOD&AMOUNT
*Industrial/Commercial DResidential Water Supply(shared) FRO�gpI7T� . IMMIIIIIII»' :`::'`':
o it TO ft
*ion..Wateon ®®-
- 112=111
Non-Water Supply Well: �,Recovery
*Monitoring ®-. .-�
Injection Well: .rr;.:o-:i:`:la'.':1�:v=;K�=s,:?�x.s k
in Groundwater Remediation s.19 SAND tAV P..ACK ii a Allen-ble`4:`-:`•''''-"EMPLACEMENTIIMEMI METHOD :_
*Aquifer Recharge FROM T©
J Salinity Barrier
�i Aquifer Storage and Recovery DI Stormwater Drainage
•Experimental
�Jl ®�._ t :.--..•�k�_fi..=az
IIIIIIIIIIIII
Subsidence Control eves-sa`�)%i'`'`" ""`=:•��eta
[�Experimental Technology DTracer a20 DIZ TO attach ESCR PTIONets fh
O� DESCRIPTION color,hardness soillrock Al o,.
*Geothermal(Closed Loop)
eatin CoolingRetum) �i0ther(explain under#21Remazks) '
Geothermal(H g/ ®l d f'
Well ID# "Cbft. MINII‘Y0 �'
4.Date Well(s)Completed: "C
c ft. Lsoft'
5a.Well Location: •--`
•
Facility ID#(if applicable)
Facility/Owner Name ,^,``w /1 4C ZiOD- �®
Physical Address,City,and Zip nR^ 2r ItE11IARKS r yt: : ;:V
L
- parcelldentificatiooN0.(EN) r��
County
longitude in degrees/minutes/seconds or decimal degrees: 22.0 cation:
( weUflLatitude oneland Ongi sufficient) 123
(if well field lot/long is suffi )N��, 02:---V)
W Date
Signs f • ed Well Contractor
6.Is(axe)the well(s)*Permanent or DTemporary B,s o mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 1VCAC 02C.0100 or15ANCAC 02C.0200
to thewell owner.
Construction Standards and that a
existing well: Yes or *No copy of this record has been provided
7.hs thisa a repair outto known
g
If this is a repair,fill known well construction information and explain the nature of the 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 pr remarks section or on the back of this form. also attach additional pages if necessary.
the same construction details. You may
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingof wells
construction only 1 GW 1 is needed. Indicate TOTAL NUMB S�MTT r�INSTRUCTIONS
drilled:' n
( [r (ft.) 24a.Forte Submit this form within 30 days of completion of well
` 9.Total well depth below land surface3@200'and 2@100� construction to the following:
1 For multiple wells list all depths if different(example- �5 Processing Unit,
(ft.) Division of Water Resources,Information
I10.Static water level below top of casing: - 1617 Mail Service Center,Raleigh,NC 27699-1617
I1 water level is above casing;use"+"
ending the form to the address in 24a
�- ( ) 24b.For Inie one
of this'form ditiOn to swithin 30 days of completion of well
11.Borehole diameter 6 above,also submit one copy
• rotary construction to the following:
12.Well construction method: 'Underground Injection Control Program,
(i.e.auger,rotary,cable,direct push etc.) Division of Water Resources, NC 276991636
1636 Mail Service Cei ter,Raleigh,
the farm to
FOR WATER SUPPLY WELLS ONLY: of this form within 30 days of
Method of test: air pressure the For Water Su 1 ls In'b iti Wells: In addition to sending
13a.Yield(gem) 1 the addresses) above, also submit)one copy health department of the county
s.
{ �Z. completion of well construction to the county P
t granulated chlorine Amount: where constructed.
• 13b.Disinfection type: Revised 2-22-2016
uali Division of Water Resources
North Carolina Department of Environmental Q tY
corm GW-1