GW1--03464_Well Construction - GW1_20240611

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1.Well Contractor Information: '
•
Garrett Clause ltt iaR © S•M : .
FROM TO DESCRIPTION
Well Contractor Name `4 ft `I\ ft.
4550-A D ftft
NC Well Contractor CertificationNumber s15xOIl Tk}R-OrXS.I1!7C„(fpr�'�mtil"ti�""c�seellss)TOXt �ifts"'1?e"`a'lei°, ".---' ^'�,,-,y} `s ':
INC •
�� TO DIAMETER TnicTis ss W TERJAL
Morgan Well &Pump, V.3^ ft' 1 ft y$ in. S Da\ Q V C
:;:zconpert#:
—Iv9 ft ft in.
gist all applicable well construction permits(i.e.t1IC County State variance,eta)
Water Supply Well: FROM TO DIAMETER. SLOT rims _ Tstarsi SS MATERIAL
Agricultural fMunicipal/Public ft ft in.
• k ,esidential Water Supply(single) ft, ft in.
Geothermal(Heating/Cooling Supp ly) ��:'i'
I IlndustriallCommercial
Residential Water Supply(shared) Sz'GR."oY1T ?ia"s- :"" ' � • .t.,'^'
FRmOM TO MATE�RIAAL EMPZ�AI�ffi•tT OD 8c AMOUNT
Nosi-Wat U _ft. l/'� ft. l�"�"iL-C_^ �U
Ls re3
Non Water Supply Well: +�-
i Monitoring
Recovery ft ft.
Injection Well: ft ft.
❑iAquifer Recharge O Groundwater Remediationa �At-
tr0oy rr;ar�r='( afir 1/4,.a came. .... .TaoD
uAquifer Storage and Recovery . Qlj SP]inityBanigr FROM TO MATERIAL
Ii Aquifer Test r3StormwaterDrainage ft.
I—`L, i 1� .'-y
Subsidence Control ft. ft. L
J Experimental Technology D r.,•--m a q E-. o
'i Geothermal(ClosedLoop) Tracer *0470111;i5PI 0a(atfac'fi`s �fionals eef' eeessar91.-'3..`r.;:i i`�
FROM TO DESCRIPTION(color,hardness,soDirvekk*el,
U Geothermal(Heating/Cpoling Return) ni Other(explain under#21 Remarks) 0 ft. 73 ft (� „ �- Ai
/ ICU Ihieft Mrr1 i'-r..ra0t-,y UM
1,2A Well ID# ( ca ft t6 ft 1) i_-iv D' +.a A(;,;
4.Date Well(s)Completed: rJ6`f, I.
ft. ft. S.ow (J"
5a Well Location 1(5' la- ft
ft ft
it y/Own2er Name FacilityID#(if applicable)
/9.5:C /11://4•C 09e_ J Si<<si —' — ft
• Physical Address,City,and Zip i C I(e._ IOE17Al: �'a :'. ?r fi7^ ,3 -.ra i . e_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(ifwell field,one let/longiisssufficient) �/C/ /
�,C N b, l 1 7b W rAil 2 "LAvi
• • Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)U 'ermanent or ©li Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
•
7_Is this a repair to an existing well: DYes or No • with 15A NCAC 02C.0100 or 15ANCAC 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same construction details. You may also?thrill additional pages if necessary.
- •
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled •
e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ►/l/`/ (it) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(4)200'w}d 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 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: construction to the following:
(i.e.auger,rotary,cable;direct push,eta)
Division of Water Resources,Underground Injection Control Program,
" 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
FOR WATER STIFFLY WELLS ONLY: to JJ �{7 -
to sending the form 90 • Method of test to
'1 10- ' 24c.For Water Supply&Injection Wells: ha addition wl
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
��** 9c z. completion•of well construction to the county health department of the county
13b.Disinfection type:L'1rr a n"�a`{ Amount: where constructed. .
Foal GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016