GW1--06349_Well Construction - GW1_20230927

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• WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: • •
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Garrett Clause irogr RZOPIEs, =s ue`',-'ms- z-'.m.v=-:. . c:7iaH�.:`,`sif ix: =<r" 4„
FROM TO DESCRIPTION i
Well Contractor Name •
tco ft I J ft
4550-A ft ft. i I ,
NC Well Contractor CertificationNumber ,.-•� I""
�15�OUTEFt_C9SING;(for„mn'lt .cased•weIIs)QRsLIN£�R('rap pcable)�,�sk=.a.::�c�,r '
. Morgan Well &Pump, INC FROM TO DIAMETER 1 THICKNESS MATERIAL
�f it ya ft f� yg in.' s v1Lt\ p v
Company Name Cl-IA-'���,.-I WI I k] T �MVerT R.
16s11\�EILCASING OR?1uifIN.(ztitbem's`[;cios'ed3oop)' , 'r°: ^'R'`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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List all applicable well construction permits(i.e.TWIC,County,State,Variance,etc") ft ft is
3.Well Use(check well use): ft ft in. ma lam'
k`li .SGBEENI.=% `•M•gS`ri Ham ig.:5sY1,71'f t. 41f"^„=y`'.'- _c..-.::.gi
Water Supply Well: FROM TO DIAMETER SLOT SILE TBICRNESS .MATERIAL
DI Agricultural DMunicipai/Public ft ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft in.hsdustrial/Commercial `1 Residential Water Supply(shared) 1..:- •��v F'} �""
1'B�GRObT.�r��.•,.::=•�i`I::`>..--;..�,�:"` :".rs".--,���._.�� .��.*���_�'Fx>•::-.�,
Irrigation • FROM TO QMATERIAL,' EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: . ® -ft' (1.9 ft 1p�` 1't�-� YVu re3
i Monitoring DRecovery ft ft.
Injection Well: ft ft.
_I Aquifer Recharge D Groundwater Remediation licafilo t z -r
1 OSAN/i GR`NV airPitG'lOOMiip 7 U-- �'
• Aquifer Storage and Recovery ©ISalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
U Aquifer Test DStormwater Drainage ft. ft
J Experimental Technology 0 Subsidence Control ft. ft •
Geothermal(Closed Loop) Traceri40:85RI11S;N( O( tttachia33 f'o`natili ein fneces`sarylti•rr=; �'`.-"�-_fi xf: °" .r-
Other(explain under#21 Remarks) FROM TO___„.. DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
J Geothermal(Heating/Cooling Return) I (xp (J ft ft r k
4.Date Well(s)Completer 'G ,-.2) Well ID# ft lJ ft 34•0(, .k \- - •
5a.Well Location: to ft .C> ft Solo V1.6 e.A—
rt.-c,rr.-SS GGC ft 'rod ft I/ / 5, - 9 Cam''
ft ft ,-.-- •' ,�R
Facility/O�wjne�r-,Name '`,� re) Facility ID#(if applicable) i; f`^•,t s n'� fr;1„'���
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(%V .1 r&A i-Kr ft. ft. 1 r-i,. {=.,,P ..i; V g•..,a.-..
' Physical Address,City,and Zip ft. ft. ( q P 9 A 7l l7
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CAS(' ::sweR1'•MgRKS-ii'€d-..� •.. vgi,:`- ._....:"Faigt, ?i-` sy;?,'ii:g„st•:c< '':,7'%= -
C'�DSr r�5 ^�,tr^ �•31 Y'�,
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CountyParcel Identification No.(P�
GA,V i:u' ',rk7
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(' rid,one llaajt'llong is sufficient) /'/ 22.Certification: )_
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Vct N l d..C.56 3. W ��f'c/I► {/ 72 2c3
6.Is(are)the well(s) ermanent or DTemporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: ;Yes or giNo with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
If thLs 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 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 attach additional pages if necessary.
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drilled: '. •
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t£D (ft-) 24a. For All Wells: Submit this form,within 30 days of completion of well
For multiple wells list all depths tf different(example-3@200'and 2@100') construction to the following:
c/a 1
10.Static water level below top of casing: (f-) Division of Water Resources,Information Processing Unit,
If water 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 for within 30 days of completion of well
12.Well construction methods construction to the following: im
(i.e.auger,rotary,cable;direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh;NC 27699-1636
CA ?rag- — 24c.For Water Supply&Injection Wells: In addition to sending the form to
• 13a.Yield(gpm) Method of test: f the address(es) above, also submit one(copy of this form within 30 days of
13b.Disinfection type:C''1r4A'1 41- Amount: gel, completion-of well construction to the county health department of the county
where constructed. �
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016