GW1--03230_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett ClauseFROM I TO I DESCRIPTION
Well Contractor Name �0 ft. 6 ft
4550-A ft ft
NC Well Contractor Certification Number
`15;©Ul'ER.C>AS1NG.formullicasedwells OIt'3ILVER;ifrs hcable -rx a `"" ' '
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERAL
ft. 6 ft ft in. V C
Company Name
,76IPTNE&CASING•OR'+.TQBIIYG;- eotliermal=c"losedloo
"ems®1 FROM TO DIAMETER THICKNESS v=- MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft f, in
3.Well Use(check well use): ft ft is
,7..S -ZL.CREEK, '>:-:
Wafer Supply
Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS ��r
i Agricultural QMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft ft. in.
c' r Residential Water Supply shared > _ ;-. -
_I IndustriaUCommer Ial � PP Y(shared) ==18:;GRObT r..,,. ;' � - -�`s:
- H ation FROM To MATERIAL• EMPLACEMENT TROD&AMOUNT'
'Non-Water Supply Well: It ft i U u(`C
' Monitoring E311ecovery ft. ft.
Injection Well: ft ft
II Aquifer Recharge ❑Groundwater Remediation
�_195SAND-31 /GRAV:EIi'3'AGEi"tf a hrsble` _
Aquifer Storage and Recovery [ Salinity Barrier FROM To I MATERIAL ~EMPLACEMENTMETFOD
Aquifer Test EI Stormwater Drainage ft ft.
J Experimental Technology ETSubsidence Control ft ft
Geothermal(Closed Loop) ETTracer a` 0"sD
I2ILI:ING;7;OG=attacli�addl4orial�aheets ifneceas` ,,.r•az -- '--===1'
.I Geothermal(Heating/Coohing Return) J Other(explain under#21 Remarks) FROM TO D C TION(color,hardness,soillrock a grain sue etc.)
U ft
4.Date Well(s)Completed: -��-Z Well ID# t7 ft v ft Vn r
Locatio vv ft
'JCV ft. ft- I O�p ft- 4,0
\ r1c ,/ �J fa� UG
Sa. ell
Fac(Ity/Owner Name 1' / Facility ID#(if applicable) r �i t 6 ft
3SVy kr'r, ft. ft.
Physical Addr ss,City,and Zip ft ft
st-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miri tes/seconds or decimal degrees- e
(ifwell Id one latllong is sufficient) 22.Certification:
N 79 w
6.Is(are)the well(s)myermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wellfs)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or JXNo 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 421 remarks section or on the back ofthis 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,%. 5—L/� 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 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,
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: fL Vv"'r 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 ���� 24c.For Water Supply&Injection Wells: In addition to sending the form to
pp++ 99� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:L'�g"-A n"�e.0 Amount: U 612 completion.of well construction to the,county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEavironmental Quality-Division of Water Resources Revised 2-22-2016