GW1--06352_Well Construction - GW1_20230927

• WELL CONSTRUCTION RECORD (GW-1) -For Internal Use Only.
1.Well Contractor Information: -•
F I
Garrett Clause f;14=z1A•`TER`z4:o ESysva;'Y ^Sg:f:,w`•-.'.�> :t .`7 ,- '1g?" ,ilf4;"'r�; =s we .
Well Contractor Name • FROM TO DESCRIPTION I
4550-A ..
• ��sft l�ft I
ft ft. I. I
NC Well Contractor Certification Numb ea- ,- """ ""
��,�13�©USf]Et:C%�I1�7G_(for..mnYfcasedweIl"s)?OR`±TI1VEltS(ifrsp'licaEle)"��--���`,�"�Mt3e. •
. Morgan Well&Pump, INC FROM 1�,+� DIAMETERI I THICIovEss MATERIAL
ft. \au ft /1 yg �m'. $ ILt\ v v 1.
Company Name C. n - �/ �• -9 4 J J ll':a, �o Pia r4; ;a ;r �=wF-
(.t' �11, /v�� 1!1/� 16..I�i1VCAfiIIYG 0Ii1It23IN.G(gebtlieal;c(ose3oo t_s '•�3•r.' is
2.Well Construction Permit#: FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Yariance,etc) ft ft. i'n-
3.Well Use(check well use): ft ft m
Water Supply well: iDi1S.CEEIM.."%A+=PAZ-.02.mV,V ttl•Iti•= Ts :u _ =wr:0.`..:_ __i
FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
I Agricultural U Municipal/Public ft ft in.
A Geothermal(Heating/Cooling Supply) `L ' sidential Water Supply(single) ft, ft in.
%ilndustria/Commercial DResidential Water Supply(shared) l�Tki•o•yB�..�,.���•.,,, .:..,;r_ ;;-..s; •�{� _ r;zt•- e;1a>. •.-r:? ># t ;;s s=,
�1S:.lT1�V.U'L•V.tA.^'�'.;iF: -r' �'Y4 '.cr,",- ' �.�:i'.'L.'3-.a.�.i? -i�r... 4 Wes.-i-n•..
I lirigation . FROMTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . . 0 ..it rip ft ,i,„ 4 c___ YV u co)
EllMonitoring nRecovery ft ft
Injection Well: ft ft
CJ Aquifer Recharge 10 Groundwater Remediation - . o
19 5AND%. .'`'VII0AF'K°�i applicable)? I SIV.O.ai:V.4• ' . ; °E?z
• Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
LI Aquifer Test 'DI Stormwater Drainage ft ft ,
:J Experimental Technology I0Subsidence Control ft ft -
Geothermal(Closed Loop) ©I]Tracer AO;Dal-W.NGROG`(oftac'Tiaddifi'o`n'ai:a`heets• ni ce+saEy)sfi ";°ar`ls_t'•.` 1 =g'
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain sire,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
d ft ft �' V•!�,"
4.Date Well(s)Completed: (qtryQ' Well ID# '3 ft 6 ftJ C'`—
5a.Well Location: ;dib ft 6vft V1�-/014,9 g fc,,,, .
06T ! �- C kitc_. GCS ft- �Sft ? Ii& --9T,f yn•}'e---
Facility/OwnerName ` _- FaciilityID#(if applicable) ft ft• '
6 e/25 �/l V'��1-L ')c et-r c kts c ft. ft 5.-
' Physical Address,City,and Zip ft. f. r s"'�C' f t I P f
l- 6s e•t Irr(-?-S- ... --- 'ZL'^'.RFamucs.,`'..r ;,--_"=_ 7si :-. `k.rTK =se-sI:tVeig`i•'.,-"-.."-';rtg54:i*4.?
County Parcel Identification No.(PIN) S E P 2 7 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . t ;�r,-f ,=r�!)1;
(if well field,one lat/long is sufficient) 22.Certification: lmoili-,'`G1. r7.c. ;
r� 7
J G�OZSO N VO; w ' SC f 4cAt j LrfLa
6.Is(are)the well(s) �ITemporary Signature of Certified Well Contractor I Date
'ermanent or
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No - 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 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. 1
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site devils or well
construction,only 1 OW-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 ifdifferent(example-3@200'and 2@100r) construction to the following:
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'I• 1617 Mail Service CentR r, aleigh,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 method: r construction to the following. 1
(Le.auger,rotary,cable;direct push,etc.) 1
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // • 1636 Mail Service Cent&r,IIRaleigh,NC 27699-1636
•
13a.Yield(gpm) Zv Method of test:.' Y( '(tJ "-'(C-- 24c.For Water Supply&Infection Wells: In addition to sending the form to
�+ the address(es) above, also submit one I copy of this form within 30 days of
13b L't
.Disinfection type: rel n 01 6.0 Amount: r7c3r1- completion-of well construction to the county health department of the county -
• where constructed.
Font'GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i . Revised 2-22-2016