GW1--00252_Well Construction - GW1_20240105

YY.l,lu..,... J.L 'n.J...,.....a......_-.� .— .' • ,
•
1.Well Contractor Information: •
•
Garrett Clause ro i' n x gfg 7 - ?r Y:>
_PROM TO DESCRIPTION
Well Contractor Name .. • 13 Co ft s\ ft.
4550-A ft ft ,
NC Well Contractor Cerd$cationNumber -xr : '-t"'r --.- "said/)O Id ligliffn'"'�"tablI : =�=.,•.�-�'et ' •
t�]S.Oiit'k���.R7G.(�foum""n`"`l,"ti�se e
Morgan Well&Pump, INC FROM TO DIMMER THICKNESS MATERIAL
)6' ft t fta y$ in. SVvt,\ Inc,
CompenyName t
/�16 OR"1 CIBIa(rertitheffipii:osed'-1 iWil> a�. ';.=u 3;V.
IrV� FROM TO DIAMETER TRIMNESS MATERIAL
2.Well Construction Permit#: Crt ft, ft. in.
List all applicable well construction - (ie.VIC,County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): z-w s 1 _�
Water Supply Welt: • FROM TO DIAMETER SLOT sT7w THICKNESS _MATERIAL
•Agricultural DMunicipal/Public ft. ft. in-
'•Geothermal(Heating/Cooling Supply) kesidential Water Supply(single) ft. ft in. •
1 shared g_ :,,:� `; '!`=K-= 5�4=w ;? sa r:.
�ilndustria]/Commercial ®Residential Water SuPP y C ) y¢�'g�G�iobT�:�� x;=����."��:�;..�•�:;�• -,a. .. �`=�� �' �--.�-;�-�-�--.�
!Irrigation FROM TO MATERIAL_ EMPLACEMENT THOD&AMODNT.
Non-Water Supply Well: • • C) ..ft. oei- ' \U`-'
p�;1,Monitormg DRecovery ft. ft.
P�In'Injection Well: , , ft ft.
'i Aquifer Recharge Groundwater Remediation GIC �lcahle��d Sr3;: ay Y
ti#: I ; ( r`P .tea:
*Aquifer Storage and Recovery . ©1SalinityBau-ipr FROM TO MA RRiAL EMPLACEMENT METHOD
*Aquifer Test
©II StonawaterDrainage ft. ft
•
I Subsidence Control ft. ft
Experimental Technology ,,_
GXOC�.'`(a'hia "ata fifi3na1,s5ieeti:�S.:nessary)E.f °a" -ai4,443a:k ?
*Geothermal(Closed Loop) �TIaceI FROM TO, D.ES ag2n1 ON(color,hardness,soil/reektype,grain size,etc.)
•Geothermal(Heating/Cooling Rehm) ^DIJ Other(explain under#2I Remarks) „` _ • 11-4 ON r�
4.Date Well(s)Completed: l.'tc'r 3 Well TO (�J ft ft, ra,kt V'`a .
35 ft. IV ft k l fj c. : C_Oir;i't_
5a lWellLocation: J
Facility/Owner Name Facility M#(if applicable) b�y
ft. ft Y +� is 2024
Igo-S � - �''h`� ft. ft
Ph170• lAddress,City,and Zip
IA-a �� A
C.) •
'✓( ;�.21�iRE1VLl27Ffi��C-: . -'=44 0.:::1:;::�E: U��4.C .�kr-tiiitcYtt:;��W4Atitc
County ParcelIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/miuntes/seconds or decimal degrees:
(if well field,one lat/longissufficient) 22.Certification:
. • • Signature of Certified Well Contractor Date
6.Is(are)thewell(s)�� 'ermanent or 1ITemporary
By signing this form,I hereby certify that the weH(s)was(were)constructed in accordance
7.Is this a repair to an existing well: pies or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Cons-auction Standards and that a
copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and Explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or 3 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 OW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
' dulled: 1-.. !\ S Uj3MTITAL INSl'KUCTIONS
9.Total well depth below land surface: 3 3.0 2 00 (it) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths:fdiffereni(example- QZ '\( `) constmctibn to the following:
10.Static water level below top of casing: J (�) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: yl(th-) 24b.For Injection Wells: In addition to sending the foam to the address in 24a
• `/ 'above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IL° r `'-g J' construction to the following. •
(La auger,rotary,cable,direct push eto.) l .
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUBTLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) ' Method oftest:bf ?Mil'[ -- 24c.For Water Supply&Injection Wells: In addition to sending the form to
rr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:L�Can"l NC Amount: I completion,of well construction to the county health department of the county
where constructed. .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016