GW1--02874_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I ,
1.Well Contractor Information:
JOil n L Fitz_ L.P.-10' i .
i 14.WATER ZONES I
We]lContractorName 4/ FROMTO DESCRIPTION
• 146 SS'—A +O v` ft. li 1 ft. g if"
2_30 ft. 23 i ft. 15.p1,M '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedse wells)OR LINER(if ap licable) '
Morgan Well&Pump, INC FROM TOG DIAMETER I THICKNESS MATERIAL
• 0 ft. s/j D ft. 6118 sdr-21 PVC
Company Name 'r r
4 Of/ZZ r /S//s 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well.Construction Permit#: O b O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. 11119 ft. in.
•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
10Agricultural OMunicipal/Public ft. ft. in. '
DGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
f Industrial/Commercial DJ Residential Water Supply(shared) 18.GROUT • '
firigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
En Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
JExperimental Technology EtSubsidence Control ft. ft. •
DGeothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(calor,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
O ft. y p ft tea- 0 j r1-
4.Date Well(s)Completed:y-!6-Z Well ID# q+ ft g 15 ft. gstil
ii S e. - Sid46
5a..Well
�Location: / OI ft 24S ft. gnu Gj.�11
/yy s et tit C .,•-tel+��l. g ft. ft. J
Facility/Owner Name Facility ID#(if applicable) ft. ft.
AI-J..ei Gam 41. ft ft. e .t b.,.'�. '&..,.i ;t ?.�,N.,.
Physical Address,City,and Zip ft. ft. r 1 n
L'ivco1N 7773 6 �i. Y 20_4
21.REMARKS
County Parcel Identification No.(PIN) tr<C P--r:r, ,2 ,:"a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35, yszggso N `EL ►@ 0/7S-5 W .
,II-1�-z1
6.Is(are)the well(s) Permanent or DTemporary Signatureof
ified We Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or EiNo 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 or 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: 2 V S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 50 (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 1/8 (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) Z'S Method of test: air 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
13b.Disinfection type: granulated chlorine Amount: . _` O , completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016 '