GW1--02868_Well Construction - GW1_20240510

• WELL CONSTRUCTION.K.B,(O1W (b-W-11 rur.�LLGII I uao v,uy. I
1.Well Contractor lnformation: • _
Garrett Clause .• zEILOM ©
FROM TO DESCRIPTION i
Well Contactor Name .. 1[(I S ft. 1 C.V, ft ,
4550-A [ ft. ft I ; •
NC Well Contractor CertificationNumber -'"KOP M-G-'6t) ,Gs(firiar f cases i e717f07,?r 4d0 firP lirabler,43--: ''cs : •
FROM TO DIAMETER Ib1
Morgan Well&Pump, INC I CIt ft ��$ in. VVC,
CompanyName �y 1 �1/ �16 CSIAYG OI2' UBLHCothem`ialtcTosed'lob��' t `r+
FROM TO DIAMETER THICKNESS MATERIAL
2.WellConstructionYermit#: ft ft in.
List all applicable well construction pennits(le.TIIC,County,State,Variance,etc)
ft ft in.
3.Well Use(check well use): c_, 3., = �V"F "yh,
Water Supply Well: FROM TO DIAMETER SLOT 516e. THICKNESS MATFRTAL
il Agricultural Municipal/Public ft. ft. in.
rffij Geothermal(Heating/Cooling Supply) lalli.esidential Water Supply(single) ft, ft M.
iiindustial/Commercial 0Residential Water Supply(shared) f s �: f.PT-. �_•�-"f-•:i:�;=.'a• ,=i a:='g=e a: s 7
ObTir. O of t :r.? E5 LACEMENTI�IT'.TROD&AMOUI T
FROM TO MATERIAL J
iln ® ..ft. ft 0 �U"(e
6Ton-Water Supply Well: Y�
Monitoring Recovery ft. it.
Injection Well: p ft. ft
**Aquifer Recharge L!Groundwater Remediation 7. ('itie 0C1 PP s „`M" n'�"I' �'�'"v
�sS`t�'D C'�. a Iica'Eile�il.t�G_•r ,:ice ,�3a;r:z��-a:L;-
�-1 Salim .Barrier FROM To MATERIAL EMPLACEMENT METHOD :r
• *Aquifer Storage and Recovery � tY ft ft.
NI Aquifer Test 0 Stormwater Drainage •
•Experime.tal Technology 0 Subsidence Control _ _ ft. ft. ^
0 MafGW(z"-•(atta`c`l'iaddi irlferiVais"• r e'ces, -G,r' 5`5P iii' •;
Tracer ����'v -
�iGeothermal(ClosedLoop) FROM TO DESCRIPTION(color,hardness,soil/rocktype,painsize,etc.)
il Geothermal(Heating/CoolingRetum) FilOther(explain under#21 Remarks) ft. ft. V ,) 10;
WellID# ft ft. VA.) 10:
'�i •
4.Date Well(s)Completed '��y� 1 ea ft S' ft Y
5a. b,, ,ocatio�np'i i -7 25 ft 165 ft . I,1 9( 9`cm r--
�(5�� A I CcC1�
ft ft
Facility/Owner Name FacilityID#(if applicable)
k-� •
ft. ft.
ugZ6' 5��� l ft. ft.
• Physical Address,City,and Zip 7c) „a= i'.r r E rfi+: Y`i t:.: .cuz +
County ParcelldentificationNo.(PIN) (� B
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: MAY 1 01 2 V 2`t • '
(ifwell fie n��ng�s ^sufficient) ` •
k_
is
• • Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)(T'•ermanent or ElITemporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.is this a repair to an existing well: )Yes or 1C4No 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 boric of thi.sforsn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Close Loop Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary."
•
construction,only 1 GW 1 is needed. T rlicate TOTAL NUMBER of wells
drilled SUBMITTAL INSTRUCTIONS ,
/�� (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For9. multipleual wellw depth below t sland surface: le-3 00'and 2 00
wells list all depths ifdiff (example- @Z @I ) construction to the following:
10.Static water level below top of casing: Z-C) (R•) Division of Water Resources,Information Processing Unit, .
If water level Is above casing,use"+" 1611 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: 24h.For Infection 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: r construction to the following.
•
(ie.auger,rotary,cable;direct push,etc.) • Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER S UYPLY S ONLY:
13a.Yield(gpm) 2 • Method oftest:•-iJ)'(C ?0-35`'►_— 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this foam within 30 days of
13b.Disinfection type:are;e;F1 e.i S,( Amount COE completion•of well constriction to the I county health department of the county
where constructed.
i
Form GW-1 North Carolina Department oflnvironmenial Quality-Division of Water Resources
Revised 2-22-2016
.
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