GW1--07847_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
i
1.We Contractor Information:
• M.UWATER•ZONES z:Z. _ ;-:-i' +'.ra:�:.-: .4 - _
FROM TO DESCRIPTION •
Well C tra for Name1 L26 t 1(07 f t 3 3�II
NC Well Co�rCertification Number 09•iQDT (for"ER;CASINGm"nlfi_ea`sed5vells);OR=LTNER(itaphcabl' e) �3F= i ;z°'�-:'
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. I/AQ ft. 61/8 m' sdf21 pvc
Company Name. �1 V �: . - ....
.16 INNER CASING:OR TUBING:(geotliermal closedJoop)T''[.... # ik;.a%=.
2.Well Construction Permit#: FROM TO DIAMETER FR THICKNESS MATERIAL
List all applicable well construction permits(i.e. C, aunty,State,Variance,etc.) ft ft in.
ft ft. 'in.
3.Well Use(check well use): .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural )Municipal/Public ft ft. in.
1 Geothermal(Heating/Cooling Supply) RIResidential Water Supply(single) ft. ft. in.
**Industrial/Commercial . • DResidential Water Supply(shared) ;28`•GRODT°;;ti:..`<i: "'G'; rt ":-:'_ :>is :_ ."-
_!Irrigation FROM TO MATERIAL EMPLACEMENT
L. METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- bentonite poured
**Monitoring LlJ Recovery ft. ft.
Injection Well: ft. ft.
*iAquifer Recharge 0Groundwater Remediation _:r_..
%c19:SAND/GRAVEL PAGICif.`a'p`p'licable)`�:�'!:'T: •`
•iAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test I Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control ft ft.
*iGeothermal(Closed Loop) DTracer 20•011 L>Ii!7GZO;G(atta¢Icidaitional'slie`eti:ifn'ecrasary)5=it - `Air '_"''rs';=,
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) DI Other(explain under#21 Remarks) ft 15 ft. �4r 1 _
4.Date Well(s)Completed: II �l Well ID# 5 ft 6 ft.�r h dl�c
c 4 b ft / S ft. �+___ 1
5a.Well Location: ([/ �►�1�7
• CLri-i-S LAC (05 " tot. ft-brown stoc lrc
Facility/Owner Name � Facility ID#(if applicable)p�i Q 10 O ft v ft �`1JG .-�ert .
ilLI30 Zip t 1 l i V V in ft. ft.
ft. ft.
Physical Address,City,an it- 7-1 t
County . Parcel Identification No.(PIMA,.., 2023
• 0F.005
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ] 22.C • cation: In Dril-1Fi:lr;1+Prc,:::50s irl i tR
351 4IZ N�c� . 3) C{ W "'°''°t( 1 ci./ , 3 .
Sigaagf ' ed Well Contractor Date
6.Is(are)the well(s);;Permanent or Temporary , •
By s: ing th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is.this a repair to an existing well: D Yes or *No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
• If this is'a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT of Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V (fti) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: t'J (ft.) .Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary , above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
• the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine completion of well construction to the county health department of the county
13b.Disinfection type: Amount: (52.
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016