GW1-2023-02516_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause
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FROM TO DESCRIPTION
Well Contractor Name IJO�j ft ft
4550-A _!UC ft ft
NC Well Contractor Certification Number s M"
15=01UTER l3ASING'for:multLcase3:wells QRT:INER"d;a hcabfe s:_ �i-.ta:.-
Morgan Well &Pump, INC FROM TO DIAMETER THICICNFSS MATERIAL
ft ft in. ILv C
Company Name �/t�) �/� �r 16IIVNERCASTN OIRTLJBING: "eotIiei$sl closed Ioo `,'•:`t
2.Well Construction Permit#: �/�" W _ � FROM ft ft in.To DIAMETER THICEN SS MATERIAL
List all applicable well construction permits Ci.e.VIC,County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM
MG'REEI To _x .- DIAMETER `SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipahTublic ft ft in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
J Industrial/Commercial DResidential Water Supply(shared) 7118:_GROUT.
Irrigation FROM TO T MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: it.
i Monitoring DRecovery ft ft
Injection Well: ft ft
_i Aquifer RechargeID-I Groundwater Remediation t v
J Aquifer Storage and Recovery DSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
nI Aquifer Test DStormwater Drainage ft. ft.
J Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer 20RTI TSNGLOG atiaclad"ditional:sheetsiecess
FROM TO DESC ON(color,hardness,so rock "»e,em) -
_I Geothermal(Heating/CoolingRetum)n J Other(explain under#21 Remarks) ft ft �,.(
4.Date Well(s)Completed:>^ Well ID# ft Cad' ft � r A -
5a.Well Location: d ft ft
qftp
�,+: te
Mark PvQS� �
Facility/OOwnerrNName Facility ID#(if applicable)
25r6 W, t/-*— yJ
1 i
-9yCi�-PS(A)k O ft. (j � V'/1
Physical Address,City,and Zip L tlt �t
T-c ��� �/?� �, ���- �l y�S �r:1zEiKAxxss: ✓ _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell fidd,one
lalat(lon is ufficient) 22.Certification: q,q
J Gj� N .-7 �� W '�/% W 5
Signature of Certified Well Contractor Date
6.Is(are)the well(s) ermanent or OTemporary
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: Yes or No with 15A NCAC 02C.0100 or 15A 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 additiotnal 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: —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200�@100) construction to the following:
10.Static water level below top of casing: /v�''� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241b.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: ```r 7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS O Y: II 1636 Mail Service Center,Raleigh',NC 27699-1636
13a.Yield(gpm) Method of test:.'!f i C(Z01rr- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�+ the address(es) above, also submit one copy of this form within 30 days of
3b 1 .Disinfection type:l.A li n a.0 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