GW1--06013_Well Construction - GW1_20241011

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1.Well Contractor Information: I i
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Garrett Clause l Y ti avm vg gf,:: - 4- 5--.,•_• • .
FRb TO DESCRIPTION I ,?^
Well ContraetorName •
12 �, IL
1(,l 1 ft.
4550 A - • w ft. ft: 1
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NC Well Contractor Certi$eationNumber ,KORO�+SR 0 IlI,C,(f9 n{ use ial-)0 2711ERt(lfsa'lic�1a„�,le); `.�r--"xx=;•_ •
Morgan Well &Pump, INC O ft '71 ft ,a,,�,,�!g in, siva\ pvc,
CompanyName 7[jZyEg CQSIG 0�2,"fi 44 etiflie c osed'lpb I "`" —
1�}.a(P.. ti?$'L.-" Pnarl,-+y?i'e_'~4.1�:--3.- cd a'c�:-,242:'
2.Well Construction Permit# C �2 _ �UZZ FROM To DIMMER TmCIQerss MATERIAL
List all applicable well constructionpermits(�a UIC,County,State,Variance,eta)
ft ft in
ft ft in. '
3.WellUse(checkwall use): _
ear r.�-z.�.I.t�,.' ,''s:�?=�," ra �-`;,: .µv�u:y.
=.FuL.�.�.�`-i:. :'�.'Ra'wr��... �?i�-'•-5�'.f;�`r,:��' 4�-t�•:_t�...r.`i'i�:_-
Water Supply Well: FROI f TO DIAMETER SLOT yl'/.N. TBIC�7ESS MATERIAL
Agricultural �I bmicipal/Public • ft ft
Geotheunal(Heating/Cooling Supply)•,. esidential-Water Supply(ogle) ft ft
I''• 4_,.'L..,. sI ntial• ox 1 share -17fr
I Industrial/Commercial i -h� Soo Y C sa�;83-�D�'rT:�-=�f�~��_-,���,�a:��-:.LL e`-`��::�'°���� ,.� "`�-r��-
I Irrigation FROM TO MATERrer, EMPIAO N ,HOD&AMOUNT
Non Water Supply Well: OCT = LG2 ® ..ft. ft ,,} ,� 1)3L,
Monitoring . ecoYery; µ ft ft.
Injection Well: Ir,::,:;, . : ft ft.
I quifer Recharge V EjGroimdwaferRemediation
kr-4 •'D' .C!.:V ii,e:itiz a.-aPAlatilgt atli ` Wejt,Ls.
�Aquifer Storage and Recovery . 01ISahmty.Banigr FROM TO MUERIAL EMPLACEMI:NTI0LEOD
1 •et Test DStormwater Drainage ft. ft •
J FsverboactdRl Technology DiSubsidence Control ft. ft i '
o �.,11 - ae.M
QR: .aaa fib kti.r pis 5ees �3 t tig;,t _
J Geotht:rmal(ClosedLoop) ®ITracer '� t`--�� c- .��•-
Otilera lam under#21Remarks) 0 ft T ft ESCRIP.uON(wlar,hardness,smvmoktpe. rains etc)
MGeothe*mpl(Healing/CpolingReium) �l l (explain CJ (/)
r
4.Date Wells)Completed:q43' u2 1 WellID# S ft ft.. CaLh ;
•5a.Wellxocation:
3a ft GS"ft' tat." (Ik&
ca!J 4. Td r '$ .Z ft. 13,101._. /5 rC.7 ,9('A:k
Farality/OwnerName - Facility ID#(if applicable) ft. ft I'
v.6 ii rC4 tQQ C. 'r"' g-Mip
T'a IY ft. •ft 1
ft ft I.
Physical Address,City,and Zip ,
County - Parcel IdentificationN'o.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or derimal degrees: •
(ifwell field,one lat/longis sufficient) 22.Certification: • ,
yS-r/025' N gel'OZf L • W sP.lket*/ .2.3 2/Z1
• 6.Is(are)the well(s)rtg,'ermanent or OTemporary Signature of Certified Well Contractor Date.
By signing this fans,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 421 remarks section or an the bacic of thi s farm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed Loop Oeotlxermal Wells having the same You may use the back of this page to provide additional well site details or well
• construction,only 1(3W-1 is needed. Indicate TOTALNUMBER of wells construction details, You may also attach additional pages ifnecessary.
drilled: • - SUBMITTAL INSTRUCTIONS
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9.Totalwell depth helow land surface: (ft) 24a,For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifferent(example-3@200'7.79 005 constnrctibn to the following:
10.Static water level below top of casing: /7 (R) Division of Water Resources,Information Processing Unit, ,
fwater level is above casing,use'4-" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.BorehoIe diameter: J,1(m) 24b.For Injection Wells: m 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: •
(Le.auger,rotary,cable,'direct push,eta)
- • Division of Water Resources,UndergroundlnjectionControlProgram, -
FOR WATER SUPPLY WELLS ONLY: // {� ' 1636 Mail Service Center,Raleigh,NO 276991636
13a yield(gym) 2 J ' Method of test: f( 'S raise- 24c.For Water SupnIY&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:c-,-„1,'1 03N1 Amount: got Completion.of well construction to the county health department of the county
where constructed.
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Farm GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources ' I Revised 2-22-2016
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