GW1--02190_Well Construction - GW1_20240408

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1.Well Contractor Information: '
Garrett Clause `y' '"
FROM TO DESCRIPTION I
Well Contractor Name No, ft. 1 ft.
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4550-A ft ft
NC Well Contractor CertificationNumber yOrL IN,G.(fpx„mn`Iti ceyed•v7e1f)1o.1t� Eg+(ifrApAlic 1'le)�•�"^�`,,=.ax-a"'"--:f •
THI SS MATERIAL
Morgan Well&Pump, INC FROM TO DIAMETER,)6- ft. . Ioc ft. 0, y8 in. SPL \ 1 vv
CompanyName16^11I1`7> CXSIIYG 0 _ C� thetSclosed'loopuY ��r=meth.:`
S/Z=1 FROM TO Drn'�rEITR 'THICRIESS MATERIAL
2.WellConstructionPermit#: ICict 1 ft ft. m
List all applicable well constructianpermits a.e.UIC,County,State Variance,etc.)
ft ft m
3-WeilUse(check well nse): _ G w :s y .:4�.�_ v :i• .
i:S:Cj ELl: � q � , -;F r2 -
Water Supply Well: FROM To DL 1METER SLOT SIZE TRICRIZESS MATERIAL
I Agricultural �vlunicipalfPublc ft ft in.
J Geothermal(Heating/Cooling Supply) 101'esidential Water Supply(single) ft �•
U Industrial/Commercial *Residential Water Supply(shared) S O, y;_ ?s�iryra W a�^ '=Fesi.r:• '`.1 r h -> . `-==Y•
Irrigation FROM TO MATERIAL EMPIACEMENT T$OD&AMOUNT
�on-Water Simply Well: •
® ..ft ft l3` ,Lk... vvLs('Cd
I Monitoring
Recovery ft. i
t.
Injection Well: ft ft
lI quifer Recharge ID GroundwaterRemediation M1--Ds l : 0RWA`1ir i1"e"j_STIM �` .3:1s, -`�
r.e�a
•iAujsifcr Storage and Recovery . QJISalinityBarrigr FROM TO MATERIAL E111PIAC NTniETHOD
NI•quifer Test
0StormwaterDrainage ft ft
n Experimental Technology I0ISubsidence Control ft. ft
MI 0'YD It`II`M.Q" I'-(a'ER.. -ad3fianal;she.342-cSS.s�Y�.a `� -`;'s`;L ':M+
Geothermal(Closed Loop) DTracer FROM TO D CRIPTIO color,hardness,soilfrocktype,grain size,etc.)
Geothermal(HeatingfCpolingRetum) �IJ Other(explain under#21 Remarks) O, ft ft �16) V‘E k-
4.DateWell(s)Completed:g44- WellID# ,-,-'''''' '''''''.." -1.-6 ft �-- ft i(eC-JA 'G�
^c� • .
gv ft. 90 ft. J"'s b---Y�n t�
5a (kck.ell cation: W /v ft '2_G ft 11___ /0 V
Facility ID#(if applicable) - •'s
Facility/OwnerName
ft. ft
gd73" /`Tana •t? c) 1�tir,�,,ieQ S •
ft. ft APRa, CG24
Physic Address,City,and Zip
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Ll� vt.1.117w1yaitu.4's ,g _...,..�_ m,.".::a?''ava..-4,:. s e�ut'•n-..-'=,s c.3-..�iv.. ms-c
GW��/ lnw,r,vCr:' ter. ^^X', - L $
County
ParcelldentificationNo.(PIN) r: .wwvw
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5b.Latitude and longitude in degrees/miriates/seconds or decimal degrees:
(if well field,one let/long is aiiftcient) 22.Certification: , .
. . W ,-.04.le'll.--. -411' );---------- nec(c-L I/04-'Z.y .
Signalise of Certified Well Contractor Date
• 6.Is(are)the well(s) •ermanent or ©ITemporary
By signing this form,I hereby cerkfy that the well{s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or KNo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known 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 ofthis form. 23.Site diagram or additional well details:'
w--Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Cle
construction,only J.GW 1 is needed. Indicate TOTAL NUMBER of wells
oonstruciion details. You may also attach additional pages if necessary.-
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drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) 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@J00' construction to the following.
LA (ft) Division of Water Resources,Information Processing Unit,
Ifwater Staticv water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617 .
level is above casing,use+"
11.Borehole diameter: (- ) 24b.For Injection Wells: In addition to sending the form to the address in 24a
•above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: it° C� construction to the following.
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(Le.auger,rotary,cable;direct push,eta.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: )J {� ' 1636 Mail Service Center,Raleigh,NC 27699-1636
`c • Method of test a('f •i 0�`�— 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy i of this form within 30 days of
13b.Disinfection type:Girei A"i 4C Amount 902 completion.of well construction to the county;health department of the county
where constructed.
Form GW-1
North Carolina Department ofBnvironmental Quality-Division of Water Resources Revised 2-22-2016