GW1-2023-02512_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause ;1:4:� zxzoNEs� s3--
FROM TO -DESCRIPTION
Well Contractor Name 7d ft. 21 ft
4550-A ft ft
NC Well Contractor Certification Number s:
r15.OT1TERCASING forinnitcasedwells ORIiI1vER; i'hcable' z ;•.
Morgan Well &Pump, INC FROM T DL4METER THICKNESS MATERIAL
ft ft in. ti VC
Company Name i(11VliTEItCASINGOlY;Ti7BING eottierinslcl"osedlao x =
2.Well Construction Permit#: FROM it ft To DraHrx R in. THICKNESS •� MATERIAL
List all applicable well construction permits(i.e.171C,County,State,Variance,eta)
ft ft in.
3.Well Use(check well use): N.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural DMunicipal/Public ft ft in.
__i Geothermal(Heating(Cooling Supply) EIResidential Water Supply(single) ft. ft in.
dustrial/Commercial I_;Residential Water Supply(shared) _ „4
1$:;GROUT .�t" '.
I Irrigation FROM TO MATE UAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: ft ft 7w'� Uv(`L
Monitoring DRecovery ft ft.
Injection Well: ft ft
J Aquifer Recharge DGroundwater Remediation
_I Aquifer Storage and Recovery !1 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test JoStormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft
J Geothermal(Closed Loop) _I Tracer 20;DRIL G:BOG`attsclz_addffionalsh"eetiif neceas -
FROM TO DESCRIPTION color,hardness soll/tock e, -grain size,eta
J Geothermal(He-ating/Cooling Return) J Other(explain under#21 Remarks) C)ft 'Z6 ft. e ;r(r
4.Date Well(s)Completed: J� ��� Well ID# ft' 46 ft
5a.Well Location:
v ft ft. C--
ft ft o%'
Facility/Owner Naame��/ /) Facility ID#(if applicable) �ft. ft. ;� r Re"
IV( / G/ G 4 -e C. Ii��- ft. ft.
III ft ft i.
Physic dress,City,and Zip
2I�eloeof&_
=Z13RBNfARKS's� � k_ 1
County Parcel Identification No.(PIN) +r r spy; 3 vRa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ll�d,on II t(1 issufficient) 22.CertificCertification: J �J
6.Is(are)the well(s) ermanent or OTemporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or ONO with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additiopal 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 iattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �6® (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'and 2 100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water We/is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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 pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // r� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
Method of test:A'r S ���'K- 24c.For Water Supply&Injection Wells: In addition to sending the form to
P the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C'11f'4 n"1 aC Amount: 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