GW1-2023-02510_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause =,i vYaTYPUZOivEs
,FR M TO DESCRIPTIONI
Well Contractor Name v ft ft
4550-A ft ft
NC Well Contractor Certification Number TERCAS able. r
ING formnlhLcasednwells�OR�IINE&'if%a ]tc .
Morgan Well &Pump, INC FROM To DIAMETER THICxziS MA
TERML
ft ft in.
Company Name /A� 1C'INNEFC;CASINGORT[TBING eotheimffig' -lao
2.Well Construction Permit#: FROM ft. ft m TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.)
�
ft ft in.
3:Well Use(check well use): u r
Water Supply Well: FROM TO DLIMETER -SLOT SIZE -THICKNESS MATERIAL
)Agricultural DMunicipal/Public ft ft �•
Geothermal(Heating/Cooling Supply) Mtesidential Water Supply(single) ft ft. in
Industrial/Commercial DResidential Water Supply(shared) 78 i.GROUT-
Iiri anon FROM TO MATERIAL EMPLACEMENT M
METHOD&AOUNT/
on-Water Supply Well: ft ft .`pni Uv(`L
Monitoring Recovery ft ft.
Injection Well: ft ft
J Aquifer Recharge [)Groundwater Remediation
19 SAND/GRA'MPAID if a livable C. . __ - •-
Aquifer Storage and Recovery J Salinity Barrier FROM To ft
- MATERIAL EMPLACEMENT METHOD
Aquifer Test JOStormwater Drainage ft.
J Experimental Technology I3Subsidence Control it ft
G
ZODR7TLTNG-ZOG"a`ttachadditioiialaheets if n`ecess v`t.'s:` =�eothermal(Closed Loop) J�Tracer
FROM TO D CRIPTION color,hardness,soil/rock e, -grainsize,etc.
J Geothermal(Heating/Cooling Rgqetum) J Other(explain under#21 Remarks) /1 ft ) ft f
4.Date Well(s)Completed L Well IN -) ft t� ft
p ft U ft.
5a.Well Location:p q e�
vft
(if applicable)
Fa IN ft
Facility I•- i
Facility/Owner Name ` ` - t
Ir/ ft ft
193� 9r. PG-I S-- GI-AIC�Y�e.
Physical Address,City,and Zip ft ft I\ry 4 J 6
^ 7n
County �— Parcel Identification No.(PIN) �y �tr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fi el one lat(long is sufficient) 22.Certification:
� 3�7G Q N �o.F g3 w
Signature of Certified Well Contractor ! Date
6.Is(are)the well(s) ermanent or [ITemporary
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: aJ Yes or D(No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additiopal 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: :I_ //� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r 6 (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@20Od 2@100) construction to the following:
10.Static water level below top of casing: �(/�,•J` (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: f 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: II 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
�" Method of test:�l-r ?CVJ5`r-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
- pp�� n the address(es) above, also submit done copy of this form within 30 days of
13b.Disinfection type:L'lrq n u'a.0 Amount: -7d l� completion•of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department oflinvironmental Quality-Division of Water Resources Revised 2-22-2016