GW1--03939_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(.GW-1) For Internal Use Only: ' { i
• 1 Wel Contractor Information: -
---AJ� —road f4=V�A1' ZONES.'.::v•: .. :;;' 3: ' cutl`. '` `:-... ". , ..
Well Contra rName OM . TO CRIPTION
• 3�l--A FROM
)41ft. PI"
NC Well Contractor Certification Number
'15::0139<EER,GASINglidr,'multi-eased.i011i)'ORLINER Kin'livable):,; .`.:r.';r;4>s...`,
• Morgan Well&Pump, INC • • FROM DIAMETER THICKNESS MATERIAL '
Company Name &• ft •6118 in- sdr-21 PVC
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f .16:�1(tiNER:CASIN OItnZ'RFBING;(Reotpeicmal"closed-loop ;;` ,:;•_JiSc'a-:;:i:)D::;;:
2.Well Construction Permit#: Li." T� FROM - TO DIAMETER TRIMNESS MATERIAL
List all applicable well construction permit..__ `e. I (,,,. _-State,Variance,etc.) ft ft. in.
• 3.Well Use(check well use): ft• ft
.:.,-• :,::it::%:,ci%:vi'..':.. :::...._o . -. f y'b':• .r
''' ''' ' ' '''''''''''''''''''. ; .:•: :FROM TODIAMETER SLOT SIZE THICKNESS MATERIAL
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ft ft. in.
I Geothermal(Heating/Cooling Supply) PliResidential Water Supply(single) ft ft. in. •
Industrial/Commercial DResidential Water Supply(shared) 18;'GROpT;; . Y '�
1 Irrigation FROM TO MATERIAL •• `EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20 ft" bentonite poured
Monitoring Recovery ft ft. , .
Injection Well: -- ft ft
Aquifer Recharge 0 Groundwater Remediation
...
19:SAND/G12eivEl•'PACIC(if applicable)• :..• .: ::•':-..,..•'••::.•':..:•‘... .; ,•. ..
Aquifer Storage and Recovery fi Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft• .ft-
i Experimental Technology )Subsidence Control ft. ft
Geothermal(Closed Loop) DTracer i 20.1i1U E121141,OG(attaciradditioiial She ets'Ifnecessary)'<•'`<;'.,::;-.:::.*:.;: ,.:
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ri Other(explain under#21 Remarks)
• C' IL K ft 'b1a.*h 0WY t
4.Date Well(s)Completed:CO(Xl l Well ID# tI ft
.36 ft'
of h rbc,
itTe:;;;;;:__ PPeni)Ar
3' ft a-i ~ `!t ft �Y� ��
Facility/Owner Name Facility ID#(if applicable) ft ft. ,.. N }1
ft ft. r a..L.l.�S V E i,.,'
q b'6 nro lyc.-Con-v( '(� f. t JUL 0 2024
P Address,City,and Zip
Wry Vie~ S . . : .,,,, ,5- „-. < . s, ; : i .
rion
County Parcel Identification No.(PIN) - DV.r..#ihs
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. • cation:
.40Sal N 10. ;1169 W ��
1
6.Is(are)the well(s)JPermanent or DI Temporary Sigma o ertified Well Contractor Date
B nin is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or :'No ' willI5A 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 neceaaary.
drilled: SUBMITTAL INSTRUCTIONS
. • 9.Total well depth below land surface: 245e (ft) 241. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3 r@200'wad 2®100' construction to the following:
10.Static water level below top of casing: O"- (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) O Method of test: air 24c.For Water Suinmly&Infection 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: 1 61„ completion of well construction to the county health department of the county
where constructed.
Form G W-i • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016