GW1--03868_Well Construction - GW1_20230609

k,�«AN:I. Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Garrett Clause14:NSTERZONES
FROM TO DESCRIPTION
Well Contractor Name
• ft t
4550-A
ft ft
NC Well Contractor Certification Number R1$:OI)sER CASING'for nulh cased wells OItLINER3 ifs licabl`e t
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS I MATERIAL
ft ft in. V C,
Company Name 16r11VPIEItC" GORTIIB.ING'eotlie_ -clpsedlaoo s t -
2.Well Construction Permit#:O��V 1 �/" - (a 62 FROM TO DIAMETER THICKNFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. f__ in.
_
Y1•?. S.CREEN:n._ ...:_c�._ - ::•x,:_Y ar:.' _-,�:�.'�:'}:_a.:����** - -- _-- -
Water Supply Well: FROM TO�~ 1 DIAMETER SLOT SIZE THICKNESSA MATERIAL
I Agricultural C]Municipal/Public ft. ft in.
Geothermal(fieating/Cooling Supply) Residential Water Supply(single) ft ft
I lndustdal/Commercial DResidential Water Supply(shared) - _ _ =fit -_-_ t- f• -- _z =__
I Eri ation FROM P-TO^} MATERIAL <=EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: it ft
If�—i Monitoring EIRecovery ft ft.
Injection Well: ft ft
I Aquifer Recharge ED Groundwater Remediation C g f
— 19_==SAPID/GRAVEI.�A 'r a livable_-_•:�'`":f � �.= >�� -
AquiferStorageandRecovery ©I Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
J Aquifer Test 3Stormwater Drainage ft ft
J Experimental Technology IOSubsidence Control it. ft
Geothermal(Closed Loop) OTracer Fla0 RIIS;7NG�OG=(atfaE a``3ifi'o'nai;�h'e`e;s ifnecea
_I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DEscRiP oN(eomr,hardness,soivroek a size etc
c % ft e
4.Date Well(s)Completed:'_ Well ID# 2a ft ft CQ-V\
5a. ell Location: � ft g� ft. town �(ti.
o U�� �� Od ft. aft
Facilityy//Owner Name
Q Facility ID#(if applicable) l�d ft 2 ft
i� toy xll �(Wt 11 {lC� CIJ��VIt� ft
Physical Address,City,and Zip // ft ft ta r T 6 ?V d�
�I�CJ e.`\ -21BEMARKS',''€_='
County Parcel Identification No.(PIN)
JU�v_�. 2Q?3`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i
f l elaUlonsufficient) Certification: DfQiSL�
�gg 1122� N �+ q ��
Wv,� � �_k
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the weli(s)was(were)constructed in accordance
7.Is this a repair to an effisting well: DI Yes or No 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 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: :;L z. 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'ang.2(a�100D contraction to the following:
10.Static water level below top of casing: So (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 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 Inethod: r 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: JJ . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l � 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:Gr-g A (6.0 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