GW1--06083_Well Construction - GW1_20241014

• • Ii'kq INV MVP
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
• 1.Well Cot tractor Information: '
• `:A'4 `LVriE ZCiNE$":.. ...":r•'•v?••.`..t' .k•:`:i:..?.K::::96;F,'; i;,'.`.,. : : i:il: .. '
Well ontract r me FROM TO • DESCRIPTION'
• 3�D-> • . . '(op ft. k fog ft / n
yvt
NC Well Contractor Certification Number • `:1 ✓
:15::Ou9:>iR:GASING:(for'multita`5ed.vCe11's}"O� R(if•ap licable)•;;':wa•�:• .t;:>:i�,
•Morgan Well &Pump, INC . FROM TO DIAMETER • THICKNESS MATERIAL '
0 ft• 3O ft •6118 In' sdr-21 PVC
Company Name V �. ... e•...;..; ..:.. .:..•.
1 s16.I DEER:CASINGORTUBING(geothermalclos'ed-loop):.:::::. .;.", .;;.. ::...-:
2.Well Construction Permit#: l b0 '53 FROM • TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction perm (Le. County,State,Variance,etc.) ft. ft. in.
' 3.Well Use(check well use): ft ft. ,in.
•Water Supply Well: sl?�SORFEN::;::;:::::•.:.;:°:;;•::;.;,,,. .: :� ..
FROM TO _DIAMETER +•SLOT SIZE. tTHICKNESS j 'MATERIAL
•Agricultural DMunicipal/Public ft, ft. in.
•Geothermal(Heating/Cooling Supply) DResidential Watec Supply(single) ft ft. in. . •
•
U Industrial/Commercial DResidential Water Supply(shared). .,isi GROUT•"'•" ": '-:'
1 Irrigation FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft- bentonite , poured ,
U Monitoring DRecovery . ft. ft. .
Injection Well:
ft. ft
N Aquifer Recharge" El Groundwater Remediation
.19:SAND/GRAVEL•PACIC(if applicable) :..=..: :•:-':::.: •' .-...•- -: •
NI Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
• J Aquifer Test 0StormwaterDrainage • - ft ft. •
•Experimental Technology )Subsidence Control ft ft. ',
1 Geothermal(Closed Loop) DITracer L
:20:.D1Ufl311s1 '"LOG:(attach-addit ar;al•sheets•ifnecessary}' "�:';:;;;;:;:"r;::`•:` :>•
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTIO N(color,hardness,sail/rock type grain size etc.)
� D ft S ft v, a.
• 4.Date Well(s)Completed: at l�`�.4 Well m# 5 ft 1 c ft jIva
rr te, Awl.-
5a.Well Location: t 1 S f 5 ft b f e W in roc_ii__
tiL n k Y1ht • _ a.5 ft ` gsft ra_r. .,
Facility/Owner Name FacilitylD#(if applicable) ft : ft `' •
°►o\ I—eU r eLV\ �UVCANII k"fl'S/ttt�i NC.'��i ft. a-•k s,.,, .., i, • n -?".,,, i.
Physical Address,City,and Zip ft ft. b
Nry .........
tlY�':it(•'L�IVL_ )-•. ':.:.; w..., -:.. 'ryc'!'T-:'�:}. v>`-Yw.-n ..:�i.
County Parcel Identification No.(PIN)
•
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G'a`'"'i 1-'"'
•
(if well field,one lat/long is sufficient) 22. 4...:.cation: •
.445 Sv b- N .4aOC) W —/
Si• �7 rtified W��( Da_(__ _44: e.
te
6.Is(are)the well(s)OPermanent or E Temporary �►
By signing t is form,I hereby certify that the we/1(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or j No with 1SA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:' , a SUBMITTAL INSTRUCTIONS
9.Total well depth belo rwlandsurface: "CDs (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: j
1
10.Static water level below top of casing: (f-) Division of Water Resources,Information Processing Unit,
• • Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/S (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
112.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 Centr,Raleigh,NC 27699-1636
13a.Yield"(gpm) 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 I copy of this form within 30 days of ,
granulated chlorine
13b.Disinfection type: Amount: 20 O Z, completion of well construction to the county health department of the county
where constructed. .
I
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016