GW1--06171_Well Construction - GW1_20241014

' I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
1.Well Contractor Information:
`-0 Tom. 3r. 1 14„WATER ZONES. ' • '
Well Contractor mm�o FROM TO DESCRIPTION :
66 47 ft. ft.
ti. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multl-cased'cveRs)OR L11IER(if appllcable);. • '
Morgan Well & Pump, INC PROM TO DIAMETER THICKNESS MATErtrnr.
1 tt. it, 6 1/8 i° SDR21 PVC
Company Name ,
^ 16.INNER CASING OR TUBING(geothermal closed-loop) ' - .514-w a t4 r
2.Well Construction Permit#: 14ta 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. ft. in.
Water Supply Well: FROM , TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑�M�unicipal/Public ft. ft, in,
0 Geothermal(Heating/Cooling Supply) I9Residential Water Supply(single) ft, ft. in.
❑lndustrial/Commercial CJResidential Water Supply(shared) 18:GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
❑Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if appL'cable) . :'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :I 26.D1tII VG O G(attach additional sheets if nceeirary) . : . . ' ''
❑Geothermal(Heating/CooliugReturn) ❑Other(explain under/{2lRemarks)
FROM TO DESCAIPT[ON(wt•r,6ardae�a,sotUroekfypggratuaire,etc.}
4.Date Well(s)Completed:2�a tt ~INWell 1D# - 2 ft. 2^ ft. (,,!` \
5a.Well Location: 6 ft. 11.o ft, [jl,,,i:,( -
-)d(__ • A _[�,l ft. U� ft. (� �+i�'
1 SAC 1 F�1 i(J�-�' 'f.' =„""
Faeillty/Ow�nerName ^'+�` Facility]D#(if applicable) ft. ft. Y , k,-_,,A,_..i +i/ y' `:i
at LO . \ V' �3oSC�• ft. ft. _ f
PhysicalAddress,City,and Zip ft. ft.
OCT 1 4 2024
L t/‘
County Parcel IdentifioationNo.(PIN) r?�,`,i tr?-3~
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long I is sufficient) /� 22.Certification:
35• t a% N S. �, • cottecie) W 3•p.1-.,2'7't
6,Is(are)the well(s): 1 1Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,thereby certify tint the well(r)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or l No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out bmwtt well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 UI 5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nndhple wells list all depths if different(example-3(200'and 2@I00)
00 ft 24a. For All Wells; Original form to Division of Water Resources (OWR),
10.Static water level below top of casing: ( ) Information Processing Unit,16I7 MSC,Raleigh,NC 27699-I617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(1IJC)
11.Borehole diameter:6 (in.)
Program, MSC,Raleigh,NC 27699-1636
12.Well construction method:rotary
, 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC27699-1611
granulated chlorine Lit
ry
13b.Disinfection type: Amount: l.K • Jo 2
Fenn OW-i' North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8