GW1--07845_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD GW-1
For Intemal Use Only:
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1.We Contractor Information: -�•: '':<'•!'.'..1 _ - A . .
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FF.Otilltra11111116111111111111111111111
TDESCRIPTION
Well C tra tor Name
• .-,.".' -''cued:
`OUTER :OliccfG fosmultr ivelr's,titan`IE
tt15: O ionsormo
DIAMETER I THICIINESS
NC Well Contractor CertificationNumber FROM
Well&Pump, INC
Morgan �� OIt7T1$ING :eotherm�close�=loop _<v�:r�x�=tis:�::•.
y1 G: . ..C: cl�lEss
Company Name �QQ ! /
FROM T® D�-
2.Well Construction Permit#: County,State Variance,etc.) ®® m -
lie(check well construction permits r 1111111111
-
Lutall aPP V:-, ._, ., ;s_ _3'... s s>� y-
_: :
`,.�7:$ERT.EN O.: - �" DIAMETER SLOT SIZE =-
3,Well Use well use): minFROM ®
1 Well: m.
IO
Water Supply �j Municipal/Public
II Agricultural 1 :iResidentialWater Supply(single) }4,1111 -:<,-- s ail <<
Geothermal(comer ial .ing Supply) (shared) '0.t.GROUT'OL. .. v$MPL' ,.II•TMET$OD&AMOIINT
11.1111111111
�IResidential Water supply( FROM TO
"'Industrial/Commercial ft. zo ft
*iIrri:ation ®®
IMO
Non-Water Supply Well:
Recovery
1111111111111
11110111111311111111111
Injection Well: •
Storage
l�Groundwater Remediation t:Zy:SAND/GRAVFIi.P.AGR"if �;lr a"ble'£ -:K.;:i`�•EMYLACEMENMETHOD
"'Aquifer e FRoar T©
"'Aquifer Storagee and Recovery
J Salinity Batrier .*Aquifer
: 1:
ili
�ISubsidence Control sue etc
tsfneces"sa`.�°:�c�'.'-•':�._.�s�_�..
Experimental((Closed logy :FROM TO OG attachDES sliee.
ON(color,hardness,soil/rock/rock r e, '
*i Geothermal Loop)
OTracer •FROM
®Geothermal(H eatin Cooling Retain) it Other(explain under#21 Remarks) it -('
Well ID# L
4.Date We Completed: L esillarginvas
t* �•1.
,
5a.Well Location: - �®
ailill
Facility MO(if applicable) ®®
Tan 'ty/Owner Name
C ,and Zip21~RR "
Ph sical Address `�n 1 f
'� parcelldentificationN0.(PIN)
County ees: DEC 0 5 2023
22.C :•,cation:
Sb.Latitude and longitude e degrees/minutes/seconds or decimal degr
one]at/long is yrrfficient)
(if well field„� �h61 W lIn '; :S r. 0 lI per -" UPI ate
Signa•� ;;f ed Well Contractor .E�`v it!`�i�
By s ng thip
rm,1 hereby terrify that the well(s)was(were)constructed in accordance
6.Is(are)the well(S)�permanent or �Temporacy this a repair to an existing well: DYes or
7.
with 15ANCAC 02C.0100 or osA NCAC 02C.0200 ided to the well owner.
IfWell Construction Standards and that a
° copy of this record has been p
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If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details: site
You may use the back of this page to provide additional necessarys or well
repair under#21 remark section or on the back of this form. the samealso attach additional pages construction details. You may
ER of wells
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having SUBNIITTAL INSTRUCTIONS
construction,only 1 GW 1 is needed. Indicate TOTAL NUMB
9.T t , 1 �. (ft) 24a.For_ Submit this form within 30 days of completion of well
00'and 2Q100D construction to the following:
9.Total well depth below land surface:
10
For multiple wells list all depths if d event(example-3[ � ( ) InformationN Processing
Division of Water Resources, Processing Unit,
the Mail Service Center,Raleigh,
1.
If Static l water level b elow top of casing: ng the 27699-1617form to the address in 24a
If water level is above casing,use"+„ 24b.For Injection Wells: oaddition s form within 30 days of the of well
(in.) above,also submit one copy
11.Borehole diameter: 6 ,
rotary construction to the following
12,Well construction method:
ound Injection Control Program,
(i.e.auger,rotary,cable,direct pusb,etc.) Division of Water Resotuces,1Un ergr
1636 Mail Service Center,Raleigh,NC 27699-1636
the form to
FOR WATER 5UPPIi j WELLS ONLY: p of this form within 30 days of
Z Method of test: air pressure 24c.For Water Su 1 &Injection Wells: In addition to sending
l� the address(es) above, also submit one coy health department of the county
13a.yield Disinfection completion of well construction'to the county
granulated chlorine Amount; where constructed.
• 13b. type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
'cmr GW-1