GW1--07136_Well Construction - GW1_20231101

WELL CONSTgUCTI6N RECORD
(GW-1
For Internal Use Only:
1.We Contractor Information: • ZONES> iu�`r={ i:;'i
iI4'•ATER DESCRIPTION I
FROM TO
!eii:oE:: Onbe
® a'�licab`leY�S`"�01.TERerEOM TO �® IIIMI
Morgan Well&Pump, INC' ® O TtAuTO- •`edtraiii clos`i-Orio. - .s.0 =:>=t=''=`"i,''
12.11011111
?16;Ii�Il`IER G95111G: R` DIAMETER THICKNESS
Company Name A FROM TO
Li Welst all aConsblewellc constt ruction
y State,Variance,etc.)
tructian permits(e.UIC,County, '
Lr.Wellppse(check ens P 1®. ,r .., y ..•::_::. 't 1
MA
F7::SCREEI�lz" = :.
3.Well Use(check well use): T® DIAMETER
� SLOT
FROM
Water Supply Well: �Municipa]lPublic -
I*Agricultural l� tial WaterSupply(single) `*::- . -
g/Cooling Supply) ©1Residen ( © _1 : :. .:"
sd�`. 43:Wit:. 4'.. ��'r.
*Geothermal comer - .- .':': . _
'- t �M >ii7 EMPLACEMENT METHOD&AMOUNT
�j Residential Water Supply(shared) •:113.'GROUT'.7.3N��'=•=;��'"•''""''''
Iiri:a rial/Commercial tiOR FROM TO
° it 20 ft 110111111
p.lO
Non-Water Supply Well: Recovery
*Monitoring D ®-
Injection Well: ^:. r g ui;`:Eifila'i7t'' :`'uv i '
D Groundwater :I9 S IG VELP.ACJ_ =,1j ble '::i`". � IsrMETHOD
ji Aquifer Recharge a FROM T®
, eandRecovery ®ISalinityBarrier
*Aquifer Storage
*Aquifer Test ®IStormwater Drainage
1111111111111
Technology DSubsidence Control size,etc
Experimental ? iLvfili
FROM TIN TO attach ESCR.FTIONets r,hardness s•:inroc- h
•
�i Geothermal(Closed Loop)
Tracer FROM TO DESCRIPTION c�or,hardness soillrock A.a,. � '
eatin Cooling Return) **Other(explain under#21 Remarkc) it
Geothermal(H g/ ••�'soft
1b
' 4.Date Well(s)Completed: Well ID# MIMI& [• .
5a.Well Location: -
Facility lD#(if applicable)
•
airaill.111111111111111111111111111111 1111131111111113
Facility/ caner Name
Physical Address,Ci an Zip tw.o S'
County
Parcel Identification No.(PIN)
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 C cation: NOV J 12Q23
(if well field,one lot/long is sufficient) � _ '; -, � rt>;
Signa f ified Well Contractor
permanent or Temporary rnt,I hereby certify that the well(s)was(were)constructed in accordance
e
6.Is(are)the well(s) By s o mg th
with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards 7.Is thissa a repair to an existingwell well:
DYes or No copy of this record has been0provided N to the well owner.
a
II out known construction information and explain the nature of the 23.Site diagram or additional well details:
If this is a repair,fill to provide additional well site details or well
repair under#21 remarks section or on the back of this form. You may use the back of this page
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
S��pA1,INSTRUCTIONS
drilled:' ells: Submit this form within 30 days of completion of well
(ft-) 24a.For_
jl For multiple wells
depth below landsurface: 00'and 2@100`) construction to the following:
9. multiple wells list all depths if different(example- ormation Processing Unit,
(ft.) Division of Water Resources,Infer Raleigh,0nN Processing
1617 Mail Service Center,
10.Static water level below top of casing: the form to the address in 24a
27699-1617
jIf water level a above casing,use"+"
` (�) 24b.For Infection WeAs: In addition to sending
11.Borehole diameter: 6 above,also submit one copy of this form within 30 days of completion of well
' rOtBr)/ � 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,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
to
Me• thod of test: air pressure the24 d ess(es)rabove, also submit oneecopy of dthis form dition to within30ending e days of
of
t 13a.Yield(gpm) completion of well construction td the county health department of the county
granulated chlorine Amount: where constructed.
• 13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
to GW-1