GW1-2023-02511_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause 014,KATER�ZONE$5
FROM TO DESCRIPTION
Well Contractor Name ( J ft (� ft
4550-A ft ft
NC Well Contractor Certification Number 15-Oi1SER"CASING,fur inulticased wells OR�LINER if a'Leable
Morgan Well &Pump, INC FROM TO DIAMETER TfficLavEss MATERIAL
ft. $ ft. in.
Company Name .r16 3NREIRCASING'ORT[JBING eotliermal closed=loo`" r f r
2.Well Construction Permit#: �V'� 13�7 FROM it. ft in.TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VI ,County,State,Variance,etc.)
ft. ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
t Agricultural [3Municipal/Public ft. ft. in.
71 Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial r3Residential Water Supply(shared) 18 GRObT.
FROM TO~ MATERIAL .,.V EMPLACEMENT TROD&AMOUNT
hri atiOIl
Non-Water Supply Well: it. ft ,-pry t Uv
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
J Aquifer Recharge oJ Groundwater Remediation
A9`SAND/GRAV:ELPAC-K if a livable - _ t,. • s ;=
j U Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL V TEMPI ACEMENT METHOD
_DjAquifer Test UStormwater Drainage ft. ft.
J Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:=DRILLMiG'I OG.'atYach'a'dditional:slieets ifnecess =_
FROM TO DESCRIPTION(color,hardness soilhvck type,grain size,etc
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) �t ft. 't r
4.Date Well(s)Completed:��Well ID# ft a ft tv T�fk
ft ft ll�
Sa.Well Location:
`_` ft. ft lam` I
rt�/�`k- PG`71'VS�� ft ft
Facility/Owner Name ,t�-/� t, F cility IDI##(if alpp_licable) - - - -
1 0 6 W�'h ft. ft. E - ;` 5 Y 3 rr- �_
T -
ft ft.
Physical Address,
City,and Zip nnon
a
d�- I-/ 21 REMARKS: -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35- 2576,5- N 90- 915 g7 W � � ,y� vq
6.Is(are)the well(s) ermanent or Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify' that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: F1,Yes or D(No with 15A NCAC 02C.0100 or ISA 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 on the back of this form. 23.Site diagram or additioRai 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water 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
`__ r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: C� construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test:,4*r ?(VJ5-1_-- 24c.For Water Supply&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:Gr4 n���.0 Amount: C.Z completion•of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviroamental Quality-Division of Water Resources Revised 2-22-2016