GW1-2023-02517_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Iutemal Use Only:
1.Well Contractor Information:
Garrett ClauselaWalxztNEs
FROM TO DESCRIPTION
Well Contractor Name 1 ft 21 ft
4550-A {• ft Ol ft
NC Well Contractor Certification Number wr
15%Op1ERCASII�IG.fo`rmu7LLcasedwells OR3INER rfa Ea
Morgan
Morgan Well &Pump, INC FROM To DIAMETER THICIGass MATERIAL
ft ft in. ?VC
Company Name
6&M4NEWGASING:01CTB aING eotherhiifclosMO
- =t
2.Well Construction Permit#: FROM I To I DIAMETER I TEaCKNMS I MATERIAL
List all applicable well construction permits(i.e.WE,County,State,Variance,etc.) % ft. in.
3.Well Use(check well use): ft ft in
a.17
Water Supply Well: .;SE
.CREN ,
_�`;,¢ ''E:.:.�._._�. _ F ..,
PP Y �,y FROM TO DIAMETER SLOT SIZE TRICKINESS
D MATERIAL
Agricultural Municipai/Public ft ft in.
Geothermal(Heating/Cooling Supply) I!Residential Water Supply(single) ft. ft. in.
�!Industrial/Commercial I+Residential Water Supply(shared) 18 GROIIT-
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 'Lpft
i Monitoring DRecovery ft ft
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remediation
'19.2SAND/GRaTVEI PACg ifa hca7ile _ _ w =
Aquifer Storage and Recovery ®]Salinity Barrier FROM TO M ETH
ATERIAL EMPLACEMENT MOD
Aquifer Test ElStormwaterDrainage ft. ft
:—')Experimental Technology ]Subsidence Control ft ft
Geothermal(Closed Loop) Tracer ;ZO:=DRII,LIl�TG:ZOG''aeiacliaddihonal heetsdfneceas m
FROM TO DESCRIP ON color,hardness soil/rock e, size,etc.
_I Geothermal(Heating/Cooling Return) _)Other(explain under#21 Remarks) 6 ft ft f
4.Date Well(s)Completed)-11-5-?l Well ID# S ft ft yP�
5a. ll ft ft Location:
( ul� s �V n C- ft
i ft �yv�
Facility/Owner Namett Facility IID#(if applicable) ft ft
C;r e&6 mjN1 ft ft
� ft ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we fie)^ ne la g0u6O
N
ent) � , W 22.Certification:
6.Is(are)the well(s) ermanent or t__i Temporary Signature of Certified Well Contractor Date
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: Dyes or �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 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:
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 ifnecessary.
drilled: '.I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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@200�anjY2Q100� 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 Iniection 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) Method of test:A,f ?(V-trl r— 24c.For Water Supply&Iniection R ells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
3b 1 .Disinfection type:C�4 n-1 QC Amount: `6(_ completion.of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016