GW1--06350_Well Construction - GW1_20230927

• WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only: '
1.Well Contractor Information:
Garrett Clause `u14= :ATEIZZ©1VL�'Sx:k�'?°;'';:".�'+'S;:Er i I s`: -s'"n''':':`YU.'•"�? : ? �..1 k;` .
FROM TO DESCRIPTION I
Well Contractor Name' •. ft V[� I ft
4550-A �] I ft l l 1
NC Well Contractor CertificationNumber fSE.Grirt aSING(form"lti cased yells)QRILINERT(iEl ialgi) ,g5M :
. Morgan Well &Pump, INC • FROM TO DIANEfk:rt ! THICKNESS MATERIAL
)6. ft -t8' ft a ` 8 �., sP t\ PVC
Company Name 16SIl NKIM-ASI Gitti` tIBIPI...G eitliex a7O edW ;r . i;.:: `:z K-.
2.Well Construction Permit#: FROM TO DIAMETER i' ' THICKNESS MATERIALc
List all applicable well construction permits(i.e 11IC,County,State,Variance,etc.) ft. ft. In•
3.Well Use(check well use): „. ft ft ?a
✓�:1:'-.S.0 REEM.f_i:M.3 ':a47. _{:ekl T.114 y r t NI c;t E r�-_i .
Water Supply Well: FROM TO DIAMETER SLOT SIZE 1 CENESS MATERIAL
Di Agricultural DMunicipal/Public ft ft in.
_J EGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) 2 •-r. .- ,F -1 A E:' --•T_ -'.P„�X"�,._Ft'Il=:V !,I -"
F18:cGRObT:r, ^`'j:r--,i='r.reaa��_���:�':°'=• .�:i�.•.�,c-� .:e... .._ c,t�.�v:,�t,�•:<: ,
Irrigation FRm t OM TO� MATERIALL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: . l.J ..ft (c ft "�"^i,y-C_r cU u ec
Monitoring 0Recovery ft ft.
Injection Well: ft ft '
0I!Aquifer Recharge DGroundwater Remediation w �,
r---.- a licaiile -Kit_ `rya>. `azi'�=ti c'"
:£19:sSi1ND%GE2>AV.EI,EAG`13f(i£-.PP �. ._ . . ��,
• Ii Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
!Aquifer Test DIStomrwater Drainage ft. ft.
.J Experimental Technology I:Subsidence Control ft ft.
'!Geothermal(Closed Loop) DTracer r.�2o1v7)ltIlipN(;ROG{attachra d tieiial;'ah lla neceasary1t i�":3fi:C`t := 0. i
FROM TO D CRIPTION(color,hardness,soillrocktype,grain size,etc.)
`I Geothermal(Heating/Cooling Return) niOther(explain under#21 Remarks) /'1 ft 4:57 ft D.
4.Date Well(s)Completed:7' "23 Well ID# /5 ft e o ft. arc)
loCi,......_ '
5a.Well Location: ft s 1 ft 4� t.•t.-
�' Ur.c.„
PJ -t ?G1\-t 6a ft r
Pt6tt-!,5f4ni lc__
Facility/OwnerName Facility ID#(if applicable) ga ft 1 Zd ft S, .. r tp �•Ki 6
`w"
YD V4- I C Ceec_ 6 h Cot,con) ft. ft
• Physical Addre s,City,and Zip ft ft. „F,t ,,-
County Parcel Identification No.(PIN) 5L L 1 u It , 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) �� 22.Certification: c! �!�' •.r'r t'• �t
•lni`Dit`2S^,it t
Sc. 4(lss r go, �:� l��a
i;
6.Is(are)the well(s)lPermanent or 0Temporary Signature of Certified Well Contractor „ Date
By signing this form,I hereby certify that the welts)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or No with 15ANCAC 02C.0100 or 15ANCAC 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 4121 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 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: Z'V(3 (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@100) construction to the following:
10.Static water Ievel below top of casing: ( J (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cent•er,Raleigh,NC 27699-1617 •
i
11.Borehole diameter: (in) •
24b.For Injection Wells: In addition to sending the form to the address in 24a
S . above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: .
(i.e.auger,rotary,cable;direct push,etc.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: II {� • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:.C •f t'J5`'re- 24c.For Water Supniv&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'�M"4 i'14( Amount: 1 1)11.• o completion•of well construction to the county health department of the county
where constructed. _
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016