GW1--07172_Well Construction - GW1_20231101

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
Garrett Clause faitiFatgR2A S; " »a= -W t•; €s; W.g,.".i+c[I52:::r',1•.
Well Contractor Name • FR ft TOOM DESCRIPTION
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NC Well Contractor CertificationNumber 15 OIJ ]RS' SlN.. for lLrssrd-%es)_OIZ17INE.Rf(if�ap If lie2ple)", ra_`,'=„``_ iw3'._ •
Morgan Well &Pump, INC FROM DIAMETER THICKNESS MATERIAL _„ ftl oft ay$ m. S17a\ PVC
Company Name 1Llifq
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6I?1II2 Cb•S]?�TCyOIZ,IlilB.IPT.0(Qeothez clase�'16op5�% ��&=� }1�;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.IJIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft m.'
Water Supply Well: y9 :5.CBF.ENV, figg r',4,—O ` zs=—�a T.--, .,tzt t:Fgr,- .-t t
FROM TO DIAMETER SLOT Size, THICKNESS MATERIAL
•Agricultural DMunicipal/Public ft. ft in.
Geothermal(Pleating/Cooling Supply) O Residential Water Supply(single) ft, ft in.
*Industrial/Commercial DResidential Water Supply(shared) e_ z r Ec y pA; -1-
IiIrrigation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT_
Non-Water Supply Well: ' 6 •.ft ft ,�On t --� Po',(1L)
Monitoring Recovery ft. ft
Injection Well: ft ft
%iAquifer Recharge IDGroundwater Remediation k ;S ANDyMIDI X' gi a hr Te > Fr g r li `a t
MIAquifer Storage and Recovery 0SalinityBam#r FROM TO MATERIAL EMPLACEMENT METHOD
:ftAquifer Test ©IStormwater Drainage fi. ft
II Experimental Technology IDSubsidence Control ft. ft •
, ,:
XIGeothemlal(Closed Loop) ®ITracer �O:gDI2IIS:nV`GROG;(a{fay'bc';arl3tionals"heeti�neceasaryj:,"Y• _..a„•�:,�� -M')..
Geothermal(Heating/Cpoling Return) �IJ Other(explain under#21 Remarks) mord TO DFrSCcR ON(color,hardness,soil/rocktype,grain size,etc.)
',ems' ® ft. �--. ft /1(;11 _y\ dr
4.Date Well(s)Completed:10 Well ID# S ft /`Eb ft tL?,.)/N V•ry '
5a.Well Location: `1 'loft. 9 ft S� S 1_,
P 0.4c1 /OAmi1c 5vft• l�v ft S4 -I (k
Facility/Owner�Naam`e Facility ID#(if applicable) I U ft Zit V(t—i s/0 — 9 ion:
.Son. +tCsr C1J � (�X(- (45�t.:-c ft. ft 1�
• Physical Address,City,and Zip y� ft ft
4.s kv/� qs�17 Z 1$07O I RNIA121ra,V. ...s. . ? SP :•f ',. f. ig W.Ra".5,Az.-.,.,a-.
County Parcel Identification No.(PIN) ,,' F^ ,. fi ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: NOV ) /
•
(ifwell field,
rone latllongissufficient) �` �� 22.Certification: IVO Y J ` `�I`3 -
1 6
w ,, ,../..,,,,,,,,,_. : ,reee,„,„..„________..„.„...,,,6461,tf C EC1.3
• Signature of Certified Well Contractor `r"`e"'y Date
•'6.Is(are)the wells) ermanent or arremporary .
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or l*o 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#21 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. •
dulled SUBMITTAL INSTRUCTIONS '
�.?c :
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 ifdsfferent(example-3@200' @100') construction to the following:
6(and
6 2
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.BorehoIe diameter: Ilan-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
11.0
It—CV r • above,also submit one copy of this form within 30 days of completion of well
construction to the following: •
(La 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
13a.Yield(gpm J) Z ' Method of test:AC ?re-st..fc-- 24c.For Water Suooly&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:are;no I Qc Amount gOZ completion.of well construction to the county health department of the county
where constructed.
Firm OW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources I Revised 2-22-2016