GW1--03828_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Garrett Clause F4-OMMTFR zoivEs �_D
FROM TO ESCRD:CRIPn TION
Well Contractor Name ft. ft
4550-A ft ft
NC Well Contractor Certification Number >p $ G<formnl cssedivpells_OR' INERitfs"liea$leA'?.— :s't
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft 1. ft in 11 V C
Company Name � (P O^1 �e w' C G"ORaT138 G `-
[�J( U"'1( '6 I11TNFIZ A$IlV IN. eotli`e`rmal;c`1p'seiL--uo t 7v ? '
2.Well Construction Permit#: FROM ft ft IA TO DMETER TffiCIINESs MATERIALc
List all applicable well construction permits(i.e.VIC,County,State,Yoriance,etc.)
in.
ft ft in.
3.Well Use(check well use):
Water Supply =s7�:5Cl2EE �,=
PP Y Well: FROM I TO
DIAMETER SLOT SIZS: THICKNESS MATERTAT•
:iJAgricultural EMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft.J in.
_ ercial _i Residential Water Supply(shared) -
I IndustriaUComm � PP
IIrl ation FROM TO .~ �.-s%MATERIAL" EMPLACEMENT ;TROD&AMOUNT'
Non-Water Supply Well: ft ft
-ii Monitoring DRecovery ft ft.
Injection Well: ft ft
J Aquifer Recharge Groundwater Remediation ...::: -- d; -:,�-•r.,:- >t�>5. t„
zZ19 r.SAND/GRX L3'ACg t£:a plicabre`
I Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMEETHOD
Aquifer Test OI Stormwater Drainage it ft. NT M
Experimental Technology ]Subsidence Control it, ft
20:DItIIIl�GOGtlaaii3i$onal;aheetsifneceesa '': - =%i;= :r_
I Geothermal(Closed Loop) QlTracer :a
FROM TO DESC TION color,hardness,soillrock `e, size,eta 4
J Geothermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) ft ft ' ) r C
4.Date Well(s)Completed.•5'LZ�Z" Well ID# ft ft roa,fi npC�� �'�;;_�r '" LP
5a.Well Location: ft (�{ t r ;23
�i0i�ifi�n Con n�^y �Gr CGS C. Od n (o ft {
Facility/OOwnerName FacilityID#(ifapplicable) �(U ft 2�J ft `J - g( ;� jfff>./dt"w3:1.^il 'f.^.•^^ g� Urt�(.
--F'Z 10 6 re, KO',t)te4
ft ft
' Physic ddress,City,and Zip � _ -__--_-_ - -__ __- _ _ z:
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latll�o/a is sufficient) 22.Certification:5. 7 70! � N 10. rr`jo Ct R'
6.Is(are)the well(s)i&ermanent or QIJ Temporary
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 eiasting well: [3Yes or 0XINo 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 ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis farm. 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: (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@100D construction to the following:
10.Static water level below top of casing: �O (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Injection 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 T 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: II 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:A'r 24c.For Water Supply&Injection Wells: In addition to sending the form to
�+ the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type:L'1 r-A fl u(6.0 Amount: 'Z 6�/ 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