GW1--07645_Well Construction - GW1_20231204

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• WELL'CONSTRUCTION RECORD (GW-11 For Internal Use Only:
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1.Well Contractor Information: .
Garrett Clause 1g`: `TEIt It s., '�-,'F.�:a'v`�, O"'_r. ;L RW4,---�• . "e "t ?'�?> u:ti .
FROM ' TOl DESCBIPTIONI I
Well Contractor Name ft ` ft.
4550-A '
ft ft
NC Well Contractor Certification Number 15�0 Crz'tc t- z-. . �. -K�
t�,..% 1�1R--9�IlIG,(fnr„multcase`dtye7ls)"bRjTTVF?Rt(ifri`licable);`�s ..:,�Z.;•'::•: '
Morgan Well &Pump, INC FRoM TO DIAMETER ' TRrcTcNrSS MATERIAL
V/3„ ft. gv ft a �/$ in,, SD'tt\ PVC
Company Name � / r .-.. ..
'_Jf6ali`li`ffELt C-ASITG OItIfiUBIlYG Re'thezmsl c�osed'lQop?°�5 sf3:' ?s�fx•v'i Vie:
• 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): in.
Water Supply Well: tt :S.011BEN % =4 :.Z ^', -1 L -1 -Vr.7A7-1Z.µ ''-= T.w.i- .
FROM TO DIAMETER SLOTSI•/.H. THICENESS� MATERIAL
-3Agricultural DJ Municipal/Public ft. ft in. •
_i Geothermal(Heating/Cooling Supply) ItliResidential Water Supply(single) ft ft. in.
I Industrial/Commercial riiResidential Water Supply(shared) $ GRO. vr "" �" V ' ustft'TIN
Irrigation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: . ® .ft. eti ft ,r,i,� YV�(' 3
DIL
Monitoring Recovery ft. ft.
Injection Well: ft. ft
3Aquifer Recharge D Groundwater Remediation _
t19'SANDY,04 a;L• 3•W apPlica le�i`id'Zi r_`_ `:.b.1. 1 ^ems -.'$-..''z =4.2.Y
I I Aquifer Storage and Recovery ©ISalinityBarripr FROM TO MATERIAL , EMPLACEMENT METHOD .
iI Aquifer Test ©I Stoxmwater Drainage ft. ft.
U Experimental Technology ©I Subsidence Control ft. ft.
Geothermal(Closed Loop) ®I ITracer •
gi20' I2) VG>O-•(atallar difinnal ih et3 fnec`essary� .;r. 's;y I .a.;?f;. ?,
Geothermal(Heating/C.00ling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(foior,hardness,snWroektyPe grain size,etc.)
(� Q /'it. t
• ft 16
4.Date Well(s)Completed:i L " O 2> Well ID# /Cv/ft ft ,`wco" V tr •
5a.Well Location: '3Zj ft. ft. S S RClttii o�
fYd&s j A rl 9`7A Z ft j ft 11. J UR./, my J c •
Facility/OwnerNaame Facility IP(ifapplicable) ft ft
6\\ f,'ec SO VAS ` 6-1J fQ CIL._ • ft ft.
' Physical Address City,and Zip 4 �} ft ft.
Comet& '3cr lei 4014 r:�2111-tEiyaitt xt.:' _.. ^s,'_-7.`..'t.:'4 =`n:�ty :J.' z`3'�K :f?°: >:t4:
County ParcelldentificationNo.(Pv7N) �`=�� i' F 1l
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: D C r L .' 2023 -
(i£wellfield,Z htt/l7giss;cient) Qk`VI ' 22.Certification: - - ^_=-V y . ,
��- )ave,shel 9 (76ti3
•6.Is(are)the wells) ermanent or �ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the waifs)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo • with ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(mown well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thi.s 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
constmction,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 sin-face: •
��� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@I009 construction to the following:
10.Static water level below top of casing: 'U (ft) Division of Water Resources,Information Processing Unit,
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Ifwater level is above casing,use"+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
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•11.Borehole diameter: Om) 24b.For Injection Wells: In.addition to sending the form to the address in 24a
12.Well construction method:
'I(1M.r Y ' above,also submit one copy of this form within 30 days of completion of well
construction to the following: I I •
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(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
13a.Yield(gpm /
) `U ' Method of test:.A( ?re�`'(�— 24c.For Water Supply&Injection Wefl:: In addition to sending the form to
the address(es) above, also submit on&copy of this form within 30 days of
13b.Disinfection type:a 4i n'4 eNc Amount: '(O O 2 completion•of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department ofBuvironmental Quality-Division of WaterResources Revised 2-22-2016