GW1--03854_Well Construction - GW1_20230609

�Pnnt:Form. ,_
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Garrett Clause i14:FYTERzONES ate.. �v-- U �- - e= L
FROM TO DESCRIPTION
Well Contractor Name
ft ft
4550-A
ft ft
NC Well Connector Certification Number rt15 OUTER=G SING,formnll cased wells OR;L7NER`if a"licabre)
Morgan Well &Pump, INC FROM 1 10- DIAMETER THICKNESS I MATERIAL
ft Slb ft in. V
Company Name Ina'SZ59 o i
MY6131VNER CASINCr`OIiBING' etlerma7=closed�oo s_ _
2.Well Construction Pernut#: FROM To DIAMETER I •rHIclavEss MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: _i17:SCREEN:�;���'�--: •,R' y.�.c .a�n�:� ^>`z��'' ` : t+v-;-.
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft ft in.
:]Geothermal Geothermal(Heating/Cooling Supply) 'J Residential Water Supply(single) ft ft. in.
IndustrialtCommercial _)Residential Water Supply(shared)Wirrigr-
ation FROM TO MATERIAL EMPLACEMENT TROD&AMOANT
Non-Water Supply Well: ft ft
L qP
ei Monitoring DRecovery ft ft
Injection Well: ft ft
'Aquifer RechargeGroundwater Remediation
I Aquifer Storage and Recovery O I Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage ft. ft.
I Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer u`20;:DRILLIl�lG OG`(attacfi addihohai:sheets
_I Geothermal(Heating/Cooling Retum) J Other(explain tender#21 Remazks) FROM TO DESCRIPTION(color_hardness,sorltrock a grain size,etc.)
q Q ft D' ft.
"r
4.Date Well(s)Completed>�2 Well ID# r� ft ft 0 to
5a.Well Location: '� ft 2'� ft /u/� \ _C� �_
r7 Gt •mac lt%A d" V ft ft �`,In"L (f R 7'T�
�GrrgUr a -
Facility//0 er Name {Faacility ID#(if applicable.) b(J ft ft. r ch
McGJ0.'J� V Cre. ft ft .`-
"' A ' —ft ft
Physical Address,City,and Zip y
County U— Parcel Identification No.(PIN) V
WhpPl6'-A:t:.il tart;;:.; ?�y l!Ri
5b.Latitude and longitude in degrees/miiintes/seconds or decimal degrees: i a vs
(if well field,one llaatllongi's)sufficient) 22.Certification:
N R'
6.Is(' e)the well(s)iA,Permanent 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: 0Yes or EKNo 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 of the 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: •7, 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 ifdierenI(example-3@200'and 2 @10 0 construction to the following:
10.Static water level below top of casing: 7 V (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: � (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: fL V-6s construction to the following:
(i.e.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL) //Y M Methodof test: (�ILLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gp (t 'r 24c.For Water Supply&Injection Wells: In addition to sending the form to
� (�—
lo- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _14-1AA 6.0 Amount: / C'2, 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