GW1--07147_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
1.We Contractor Information: sZpS, 3 to l- .ti.,... _
FROMTO DESCRIPTION
FROM
WellC tra tor Name FgaillM
'ifs�';lieab7e:s- `r"•� •'h``'�
CAS7NG"fall t ,jv' s',OI%10ENEg.
:e15'r`AnTER. D THICKNESS .. 1
NC Well Contractor Certification Number FROM
TO sS ; R
Morgan Well&Pump, INC :OR IBINa•euthef elande`d=sou, ,.Hk:
111111111
1671HNER:G9SIPIG DIAMETER Tffi�mium '
Company Name. W J �` ®FROM T®®
Well Construction Permit#: state,Variance,etc) -
2. well eonstruatian permits fl.e.UIC,County, ®®®`��-.
List all applicable _ .•:_..,_._ ::.• �='� "�"•'-•=_
11111111111111
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�r:?: %. :.W.::-a_ LESS
Water3.atell Supply Well: e): FRSCREEPTO` DIAMETER SLO�=-
FR�®®
1�MunicipaUPublic -
g Agricultural Geo ll''_°i esidential Water Supply(single) ®- *: ,: 1
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Geothermal(Heating/Cooling Supply) )R © :�,,:.r;:.: ::'' _ ._._
*Indust al (H� .• OD&AMOUNTS
Residential Water Supply(shared) _Fs3 GROD�' '� - '' 'tY"resi 1 EMPLACEMENT MIT$
(�ilndustriallCommercial FROM TO !Cc®��
D ft. 20 ft.
Ihri:ition ®®-
Non-Water Supply Well: Recovery
11111111111111111111
*Monitoring •., ._,
Injection Well: NTMETHOD
IIIIIMIINIIIINNIIIIINIIIIIIIIIIIII
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I Aquifer Rechazge DGroundwaterRemediation t,• y S 1 VFdi.Y9CK rf:z �licable' •,5.
SalinityBameI itmillosoli FROFRO® T©
��iAquiferStorageandRecovery
�i Stormwater Drainage
SiAquifer Test .... :I tr.I
Experimental Technology °1 Subsidence Control au eto
ti•T:OG'atfscji�ad'ditionaLs7ie`etsf'neces ):}'�-•"=•' .•.
'e;FD D DESCRIPTION color,hardness,soiVrock I.e,: '
r Closed Loop) Tracer FROM To
*Geothermal( ft. � ` 'r
*Geothermal(Heating/Cooling Return)
Other(explain under#21 Remarks) ft
1131
Well ID# ® �5
4,Date Well(s)Completed: b 111 Im ..
Sa.Well Location: 1111111111111111111
Facility ID#(if applicable) 11111011110
Facility/Owner Name NI C 2 w 9 - '.11111111111
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3 1�
Physical Address,City,and Zip 12r •' .< "is .ti •,:R
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PazcelldentiflcationNo.(PIN)
Countyty •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 C . cation:
(if well geld,one latllong is sufficient) 1
?>C 5Ae�6 N Date
Signa f • ed Well Contractor
Tern Diary that the well(s)was(were)constructed in accordance
6.Is(are)the wells)*Permanent or P By s rig th rnr,I hereby certify
+ T with 15AI�CAC 02C.0I00 or 0���to the well owner.
Construction Standards and that a
I.Is this a repair to an existing well:
Yes oro copy of this record has been p
' If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details
repair under#21 remarks section or on the back of this form. You may use the back of this page to provide additional well site o attach additional pages if necessary.details or well
S.For Geon on or Closed-Loop Geothermal Wells
construction,,onlyy 1 1 GW-1 is needed. Indicate TOTAL NUMBER
of wells the same construction details. You may alsSIISMIZ,TAL INSTRUCTIONSgrilled ' 3a5
(ft.) 24a.Forte Submit this form within 30 days of completion of we
ll
For multiple wells list all depths if diff e r
9.Total well depth below land s 3@200'and 2@100') construction to the following:
unt(example-
Processing Unit,
_t (ft.) Division of Mail Water Service Resources,Cres Raleigh,Information Processing
10. teatic l is above
level below top of casing: the 276for99-1617
o the address in 24a
If water level a above casing,use"+"
6 (in.) 24b.For litc lieu yells: 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:
12.Well construction method: Injection Control Program,
rotary,cable,direct push,etc.) Division of Water Resources,Underground
(i.e.auger, tart, 1636 Mail Service Center,Raleigh,NC 27699-1636
the form to
FOR WATER STIFFLY WELLS ONLY: P of this font within 30 fors of
Method of test: air Pressure 24c.For Water Su 1 &IR bmit Wells: In addition to sending
�^ the addresses) above, also submit one co Y health de artment of the county
13a.Yield(gpm) completion of well construction to the county P
granulated chlorine AmountliA where constructed.
13b.Disinfection type: I Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
dorm GW-1