GW1-2023-02508_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Garrett Clause t2[4 WATM�zONEs O..
FROM TO DESCRIPTION I
Well Contractor Name 1 66o.) ft G ft.
4550-A 1 ft. v ft,
NC Well Contractor CertificationNumber 15OT]TEREASIN,G,for<mnitieasediwells OR3INER ifra`'hcable
Morgan Well &Pump, INC FROM TO DIAMETER THICIIDVESS MATERIAL
ft. ft in. vC
Company Name / ,/, ,�UMNMCASING,ORTUBING*eothermal-ilosedloo a F
2.Well Construction Permit#: I v y 1 J?/2 �9FR
oM To DIAMETER THICIaffss MATERIAr
List all applicable well construction permits Ci.e.UIC,County,State,Variance,etc.)
ft. ft. in
ft. ft.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipabTublic ft. ft.
:)Geothermal Geothermal(Heating/Cooling Supply) 0-Residential Water Supply(single) ft. ft. in.
Industrial/Commercial r':Residential Water Supply(shared) 18 GRODT '�_ } i`= '- .•.r•, v v
Irrigation FROM TO�= MATERIAL ..,.EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: ft qP ft +0A U��
Monitoring []Recovery ft. ft.
Injection Well: ft. ft.
_Aquifer Recharge ED Groundwater Remediatlon
Aquifer Storage and Recovery !J Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test
_I Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
J y
>UDRMU NG.I OG'attneli'additional"s`heets ifnecess
Geothermal(Closed Loop) �ITracer '
FROM TO DESCRIPTION color,hardness sail/mek e, size,etc.)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) U ft. 2� ft. r-
4.Date Well(s)Completed: Well ID# e� ft �� ft. lv ��
c, ft ft ✓�
5a.Well Location:
OG)r C-�nLf's �F cif-61-C ft ft
i
Faff!rf
N�me Facility ID#(ifapplicable)
ft ft
GI ��rl f! ft. ft.
ft ft.
Physical Address,City,and Zip
/�GC-�i(LO 7✓�/I O V�� y V't..Jy1REMARKS _ '._
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +L•; r ;
(if we tie latll�g�s�cient) ,mil •� 1 22.Certification:
nJ - N X a U �6 W
a
Signature of Certified Well Contractor Date
6.Is(are)the well(s) ermanent or Temporary '
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well Yes or No with 15ANCAC 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 of the copy ojthir 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
drilled: t _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G> (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2y0' d 2@100D construction to the following:
10.Static water level below top of casing: LL (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: Cm•) 24b.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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test•. I�(f ?(V_01r_-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
��++ nn the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:l' 4n��Q� Amount: U'y 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