GW1--05350_Well Construction - GW1_20240909

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
• 1.Well Co tractor Information:
•
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FROM TO DESCRIPTION
Well ontract r me
• ° k'k '?"t kO S ft. 1O� R 1 QO it
ft, ft
NC Well Contractor Certification Number .1>`':
:IS::Otl'Le.R:GASTN6:(for"multitased.wells)'ORLINER(ifap licable)'t�:':�<:>:�.:`•"1,,..:
• Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL '
0 ft. 4i4 ft '61/8 in' sdr-21 PVC
Company Name ..
p1' AA�� Q ::16:�'1�INERCASING.OR:ZTIBING,;jgeb�ttiecmaiclosed-loop)'.: :..;.'';�:":�:::>..�.,�.;,:,•:..:..
2.Well Construction Permit#:Se�R„ " —�fb l� FROM ' TO - DIAMETER THICKNESS_ MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. m•
• 3.Well Use(check well use): ft ft in.
17:SCRSE,N::: .• ,.. q,:.. .. • ..
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural EiMunicipal/Public ft ft. in.
X Geothermal(Heating/Cooling Supply) IIIResidential Water Supply(single) ft ft. in. '
®Industrial/Commercial (Residential Water Supply(shared)
i Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft- bentonite poured
X Monitoring QRecovery ft. ft •
Injection Well: ft• ft
A Aquifer Recharge' ID Groundwater Remediation
19:SAND/GRAVEL'PACK(if applicably :..• ..:
*Aquifer Storage and Recovery f Salinity Bamer FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test fl Stormwater Drainage ft. ft
X Experimental Technology [)Subsidence Control ft ft.
X Geothermal(Closed Loop) EliTracer 20:.DRILLID(GLOG(attdclradditional'sheets'ifnecessaryj'": c:>:'::: ::'.;-::.:;,:•':
(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
I Geothermal satin Coolinog etum 6 ft• a
4.Date Well(s)Completed:O 1 y''1 Vi Well ID# S it
IS. ft .4 row1'1 Qlkit-Le
5a.Well Location:
R0-. I5 ft 3b ft. -+telit —r�A—
ge It.rc. ` ' ( 30 ft Sob ft. t3Y� g r�1 ie..f. , `—
Facility/Owner Name Facility ID#(if applicable) - ft' . ft • ..� %.1 L.; � 1_Li
1..0303 TScwwnavt 60-rrtt,r Q1 YINO)Itsst G $
. El t ft.
• SCE' 0 0624
ft. ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN) CoNC:orl OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one tat/long is sufficient) 22. r' cation:
'3 . 3?4 N 10 t-b56 W 4)-5 )-4
6.Is(are)the well(s)JPermanent or niTemporary Si, rtified W C or Da
By signing is form,I hereby cerisfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or >�No 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:' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Sob (ft.) 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'end 2@100') construction to the following:
10.Static water level below top of casing: 35 (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) I Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
rr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: e)` a z 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