GW1--06353_Well Construction - GW1_20230927

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.•
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1.Well Contractor Information: •
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Garrett Clause , = •:`-µgo"'� _�=.c`.- ::"- `_�'-.� A-7,3, ;
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Well Contractor Name FROM_ DESCRIPTION 3
' Oft 1 I ft
4550-A ft ft. f I
NC Well Contractor CertificationNumber ifn ]eable 'r:
labla13'EIt_CW,SING(f elfin `t cased i'e71ilitiA IMI p .•� )`r"-e^.t ±�'
. Morgan Well &Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL
ft 63 `I$ �n snV.t\ �..pvc
Company Name )6 I-• ft2 CASINCr0f 13_INC gotlill-. la lvitt\ =v'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
`��:$ 1 .-5.1.t,•e�.;Wit. �;.kl ,,... _ r e4=wren•"::=':A
CREENr:,-:.�•k�=x...a„.�i.�•s_�; r�,�twr�a��� _:..:.��. F..___....4:;.t;.i' -
Water Supply Well: FROM TO DIAMETER SLOT Ci7E rnTHICKNESS MATERIAL
j Agricultural )Municipal/Public ft ft in.
riii Geothermal(Heating/Cooling Supply) ILPResidential Water Supply(single) ft ft in.
•industrial/Commercial DResidential Water Supply(shared) -•s:� _ e-;,, .p, . - iyz:_: =a� r�'�t •"="-"
`�B�GROI7T< .: . .�: .�- ,: { -ice :+,��us�•::•,
:i= 'gation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: . 0 ..ft ft , .-t.1- VU u eea
Monitoring ritRecovery ft ft
Injection Well: ft ft
Aquifer Recharge DGroundwaterRemediation Y;a• ,q zRa, z :;'K �
""19?SAND' aldt ,EAC1 (if.applicalile)C; .�: _ «;i aa=;..:. :x a. -.c.a
• Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) DTracer c4211"a3iltlITaIGXOG::'(attaaarid tio`n'al ehee'ts ece+sary)Yza t;M.'�• ==fWAli #;:
FROM TO DZSCRIPTION(color,hardness,soilhncktype,grain size,eta)
Geothermal(Heating/Cooling Return) In Other(explain under#21 Remarks) k-
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4.Date Well(s)Completed:q^17, 10 Well ID# c ft --- ft' $fot•+n `,.cr t— -
5a.Well Location: 2 V ft, a ft 4 m,, .r C
�iji#1 Gr CA.s\-' so ft t f ft. 1Xii k/4 9 ran ht-.
Facility/Owner Name .Facility ID#(if applicable) ft ft.
• c"36 1 in rel V,,p Aif Concorc) ft ft
' Physical Address,City,and Zip ft ft -ii, --( ' .a,a r,.F r-4
C4xt us �+ il1•"iRF.NL'A�2K .';r._'ex ..=._�=fir _:.•:.3,:::: :.i?;_cji:"'-'" �:ro:x-•w=`'- '.sw4,1.
County Parcel Identification No.(PIN) .S Ef y 7 202 J
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: Ifti^.1iY+ti;'^ 1 rI ,s,;ia,:t?3 ins;:
(ifwell field,one lat/lo g is sufficient) 22.Certification: d .�,•�, •
.1� 58Ja N go,c71'76. w j:.dcf�
6.Is(are)the well(s) ,Permanent or ®I Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that rite well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fi11 out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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
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construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction detaile. You may also attach additional pages if necessary.
drilled: 1.. r c� SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 1 V (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@100) construction to the following:
10.Static water level below top of casing: VC) (ft.) Division of Water Resource's,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Centi r,Raleigh,NC 27699-1617
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: 110k- construction to the following:
(i.e.auger,rotary,cable;direct push,etc.) j .
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY/WELLS ONLY: // . 1636 Mail Service Centl r,Raleigh,NC 27699-1636
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13a.Yield(gpm) G/6 Method of test:.-4(C ?re-6,-(5-- 24c.For Water Supply&Injection 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.Disinfection type:argil 016•C Amount: rin 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 Revised 2-22-2016