GW1--03940_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. •
• 1`We�l,Contractor Information: -
jam ' 4':q}A1E72%ZON .::y •r '4ia:i'�t'a'` c- y .. . . .3
We1lCont rAlame FROM . TO • DESCRIPTION
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NC Well Contractor Certification Number L ibtr ER,CASAe:fdr in"-haa4II ieUs ORLI(VER if a.*lira le " •
' Morgan Well&Pump, INC A ) c P*liable) RI' :r%'. >:r.
- FROM TO DIAMETER THICKNESS MATERIAL '
Compahy Name 0 ft• ft '61/8 in• sdr-21 PVC
•
�/f .16.�TtaifiltCASG INOR:XT.I G;(geglbecmalciosed-loop):: :: ':::_';:`:.�5•a::S :::i.
2.Well Construction Permit#: •3`C�11 FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) - ft. ft. in.
' 3.Well Use(check well use): ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE• THICKNESS .• MATERIAL
I Agricultural f Municipal/Public it. ft. in.
*Geothermal(Heating/Cooling Supply) IMIResidential Water Supply(single) ft. ft. In. .
a Industrial/Commercial OResidential Water Supply(shared). ::I8;'GROUT;..' . ,...,,,, .
_(Irrigation • FROM TO MATERIAL -EMPL▪ ACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft• 20 ft- bentonite poured
1f Monitoring DRecovery ft, ft. .
Injection Well:
ft. ft.
•Aquifer Recharge nGroundwater Remediation
19:SANIYIGRAVEL'PACIf If a lcable .•
"'Aquifer Storage and RecoverySalim Barrier C T ) A C
g �Salinity FROM TO MATERIAL EMPLACEMENT METHOD 4. .
•Aquifer Test fStormwaterDrainage ft. .ft.
•Experimental Technology rjSubsidence Control ft. ft.
a Geothermal(Closed Loop) r3Tracer :2o:.1SIlIEL•Il101:0ii(attidetaiddiiborial'sheets'ituecesssry) :.::`:;•:::::".':::::...:::•;:::
(Heating/Cooling gReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal eatin Coolie 0 ft. ,b ft. brow* duet
4.Date Well(s)Completed: � ( iveU ID# ,b � ^' b� ("f our rhe.
5a.Well Location: ( '30 D.� t � �Y rW`
f.k-e.,
F ility Owner Name 5 Facility ID#(if applicable) ft. ft.
_� ( .`.
W✓t.. _\\S Aft, 2.49j46, ft. ft. JUL )A
Ph -al Address,City,and Zip ft ft 0 V Z�Z4� 4 r
'/t County Parcel Identification No.(PIN) o iiC'r;
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -_
(if well V ne lat/long is sufficient) Q� ^�-�� 22. tification•
S •
' 3 N Off. do W r{ l/;f�_rtjI , �
6.Is(are)the well(s)JPermanent or Temporary Signa e o ertified Well Contractor a {^
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: DYes or IgiNo with ISA NCAC 02C.0100 or ISA 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.1SUBMITTAL INSTRUCTIONS
. 9.Total well depth below land surface: (945 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200•and 2 a@100) construction to the following:
10.Static water level below top of casing: 3 d (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
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.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) t 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: lafi 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