GW1--07137_Well Construction - GW1_20231101

For Internal Use Only: '{
WELL CONST1aUC_ R
ECORD _
Contractor Information: ;.;;32;1; =;';�::..•.I • .
1.We Con ;a14;;WATERy7,ONES;=. DESCRD'rION
wo OO1V1 TO
tor 1+'j"1
Well C tea _
_.^ '_ edivells'ORS ]icable
• . ''i5'0131 70BISG focSmult cos g MATERIAL
M111113111111111
NC Well Contractor CertPcationNu INCFROM o DIAMETER I THICKNESS
Morgan Well&Pump, NC ®[ �����er 2/too, 'r.
9 cAg>riG.ort7
a�16:IN1vR D�.� TffiCKIdESs
Company Name, , `�h � FR°M T®®-
2,Nell Construction Permit#: C.��C {CJ�Ty Smote,Variance,etc.)
3. all applicable well construction permits(i.e. 1111111111111131111116111111111111111111111111111.. ... .:..-.•._'? 1'=:'c.t
3,Well Supply
Well:
l use): • =FR:SCREEL OM TO '=--=^'..DIAMETER SLOT SIZE _Tffi�=
Water Supply WeII: �j Municipa]/Public
I*Agricultural LtSupply(single) ®® in' 1111111111111111111111111111—
•
ting/Cooling Supply) i';;Residential Water ( ..4. .,:::::,.:;y-'-:;._�.•-:,� ., �'�;;:.
Geothermal(Hea Water Supply ) ':581'GliO ta; Ci F V LACEMENTMETHOD&AMOUNT
Residential pp Y(shazed ,,.. >
(*�Industria]/Comvlercial � FROM TO
o ft. 20 ft EMI
*i&ri:ation ®®®*Monitortering
Supply Well: D
Recovery
11111111111111111111111111
*Monitoring 1111111111113111111111 �' :A.r: . '
Injection Well fOGroundwaterRemediationO IMEMBIIIIIIIIII ygl,poFMENTMETHOD
•
*Aquifer Recharge i;19ISA1TIilAQEI.PA( ifs,,livable` ::_"::
J Salinity Barrier
FROM
T©
*Aquifer Storage and Recovery is Aquifer Test �Stormwater DrainageINIIEIIIIIEIIIIINIIIIIIIIINIIIIIIIII •
IIIIIIIIIIIIIIIIIIIIIIIIIII
Subsidence Control • •,sue etc.)
I*Experimental Technology D O;G attach- 4.4-4.-i r,hardness
•soil/rock
-ck- h
j;FROM
T DES •r TI•N color,hardness soi/rock A.e,:
�i Geothermal(Closed Loop) DTracer FROM TO
eatin Cooling Return) NI Other(explain under#21 Remarks) b it. ft. irsi .r
Geothermal(Heating/Cooling P� iony ft 0 . J t
Completed: Well ID# 5J
4.Date Well(s) p :- :
llL0cation: i rams '(Oc k
Facility ID#(if applicable)
Facility/Orvner e ► V.
y a 2e �
aaas
UPABMIIIIIIIIIIIIIIIIII
Ph sical Address,City,and Zap 11111
ir2T -' ::`'~
t _
Parcel ldentificahonNo.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: NOVj n
22.C• :.,cation J Z1/2a�
(if weell��field one l�atf/long is sufficient) �y r a
35 �.4 G� N a 0•'(O Y W J:L� Inc' .. ^.9n,2 �ei1
edWellConhactor u,t ., : 4
Signs,., ;f �'^,
i
6
t
well
7.Is(are)are repair to
permanent or Temp°racy By s:ing tic rm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or]SA NCAC 02C.0200 Well Construction Standards and that a
to an existing well: Yes or ° copy of this record has been provided to'the well owner.
7.Is thisa well details:
If this is a repair,fill out known well construction information and explain the nature of the
23.Site diagram or additional w.
repair under#21 remarks section or on the back of this form. You may use the back of this page to also attach additional pages if necessary.rovide additional well sitetails or we
ll
the same construction details. You may
c.For Geoprobe/DPTG - Closed-Loop Geothermal Wells hBE of wells
constmction only 1 GW-1 is needecL.Indicate TOTAL NUIvID S_i_—T�INSTRUCTIONS'
dried t ^/ y5 e Submit this form within 30 days of completion of well
�+� (ft.) 24a,For AIl
9.Total well depth below land surface:
t(example-3(200'and 2@l00D construction to the following: I
t For multiple wells list all depths if different( p Division of Water Resources,Information Processing Unit,
(�O (ft.) Raleigh,onN Processing
10.Static water levela below top of casing: 1617 Mail Service Center,Rat ig ,
1• If water level is above casing,use"+" the form to the address in 24a
24b.For Inie�R'els: In addition to sending
y 11.Borehole diameter: 6 (m) above,also submit one copy of this form within 30 days of completion of 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 Inj
1636 Mail Service Center,Raleigh,NC 27699-1636
the form to
FOR WATER SUPPLY WELLS ONLY: of this form within 30 days of
5 Method of test: air pressure 24c.For Water Su , &In ection Wells: In addition to sending
13a.Yield(gpm) the addresses) above, also.submit one copy health department of the county
O� completion of well construction to the county
granulated chlorine Amount; where constructed. 1
13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
dorm GW-1