GW1--07647_Well Construction - GW1_20231204

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• WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
1.Well Contractor Information: i
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Garrett Clause 1'4.irr g&RZO1 E'S,`;asWE.'ci-v1w µ 5 WA 'e c ^g=:,i'ia� `.`cols
FROM T
Well Contractor Name 1 ft i S DESCRIPTION'
5. ` ft, i i
4550-A '
ft ft I ,
NC Well Contractor CertificationNumber -,rs•15 OLI IIt;C f,S.tt a(fps,.mull4caseav7e71s)_0 1 )it(ifrip"lirzble) '-w" $
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
J„ ft. • it, ft /1 yg ini s l) \ ? V 1.
Company Name �iir`� e:_ ,. • .. O al osed'-1' ,"< s.=, r y
q1b;17Y��'L2CA$IIYC��0127�ffBI1�.C:;�eothenm. tiopj`. .,�:.�>�r..V_n•=�:3�C.;,;'•�i:
2.Well Construction Permit#: FROM TO DIAMETER ! THICKNESS MATERIAL
List all applicable well construction permits(i.e.'WC,County,State,Variance,etc) ft ft sn
3.Well Use(check well use): ft ft in.
Water Supply Well: 1r[ :SCREENr' .'.Zeki ..;M CT.Y K a r:ti;a17�=r: .P• .
FROM TO DIAMETER SLOTSia: THICKNESS MATERIAL
I Agricultural DMunicipal/Public ft ft. in.
11 Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft in.
*Industrial/Commercial DResidential Water Supply(shared) _ y �-
"',�.,1S,:G10�OT���^``.�i� '(:r�r '�"'�''��i�A'��Y.r�---��i ,;%�`Y�t-�ti�#��:"s�pnc.
Iilrrigation mom TO MATERIAL r EMPLACEMENTI¢ETHOD&AMODNT
Non-Water Supply Well: ' 6 ..ft ft ,]Y,�,t 4.,C-- Vp u re
Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge It Groundwater Remediation
.d.'.19 iS'41NDY,Q2:Wi :S.Mi +apphca'lile,1i,.f.A.r .c—.. vim_'c3" 'R ,11 s
DAquifer Storage and Recovery ©ISalinity.Bamer FROM • TO MATERIAL EMPLACEMENT METHOD
DI Aquifer Test 0 Stormwater Drainage ft. ft. .
gExperimental Technology Q Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer fLO'�DNIQDNQX.0-'(atia 'a 3 fin ltri Qts:ifin67-air rYl.Y -s 4 *;��-;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,seWxeelctype grain size,etc.)
4.Datekk-q-'L1 ()v ft.
V(�f ft t �� • ' - .
Well(s)Completed: Well ID# �J t v ��,/�
5a.W Location: (� ft. ft. o 'Loc ,
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(q�(S '�j� �,,� (�-ft ! 5ft ` I� rt.�- ran% _
ft ft 9 5
Fac 'ty/W.. rName Facility ID#(if applicable)
IC2-....SI O q-1 C� ';``� CS�Mel•' V ft. ft.
• Physical Address,City,and Zip g—t .
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: ID C r 7 !; 2023
well find,one 1 ongis sir cient) �.^ ��� 22.Certification: ._:.^ _:`.• .
v Signature of Certified Well Contractor Date
• 6.Is(are)the well(s),� armament or 0Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: I Yes or EKNo 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.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or CIose�t-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.-
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drlled: "� SUBMTITAL 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 if different(example-3@200'anndd)2@100) construction to the following:
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
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11.Borehole diameter: (m) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1(40 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following- •
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(ie.auger,rotary,cable;direct pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f . 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) �� ' Method of test:.F►(( ?COO'(C-- 24c.For Water Supply&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'1M 4 n'II
� Amount OVs. department
completion.of well construction to the county health of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016