GW1--03232_Well Construction - GW1_20230511

- Print Form.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause 14 wax>1zoNEs
FROM TO DESCRIPTION
Well Contractor Name 2 6 ft. -b-1` ft
4550-A ft ft
NC Well Contractor Certification Number
UTER C>ASING for.mnlh cased-``w`elLs OR�I INER-if a"hcable_= � . .-='-
Morgan Well & Pump, INC FROM TO DIAMETER i THICKNESS MATERIAL
it. ft in. 'L V r'
Company Name = -
/I��' /I�_�0�� �n� .�36"SINNER Ci15INC:OR:T'QBING',eottiernisl=clnsed3'oo '=. �....-
2.Well Construction Permit#: f V V (� FROM TO DIAMETER TffiCHI�SS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• ft in.
ft ft. in.
3.Well Use(check well use):
17:;SCREEN '
Water Supply Well: _-
PP Y FROM TO DIAMETER SLOT SIZE THICI{NFSS MATERLAL
:)Agricultural Agricultural i�i Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) %-Residential Water Supply(single) ft ft in•
__I Industrial/Commercial DResidential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: —6--ft-71P ft. 14
t Uv�
Monitoring DRecovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge Ci Groundwater Remediation
19%SAND/GRr1'y TP, Z Ufa 'livable
D Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3-1'Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer -20 DRIIXING'1 OG atticl idilfti6inlihei6lif n&—esgiiyl =
V- 0�-
TO DESCRIP ON(color,hardness,soil/rock e, m sue,etc.) `
1- Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) eft E-�
rw
4.Date Well(s)Completed: I Well ID# rPt'�/'
Sa.Well Location: ;1 ft � /t__ ec,0 ft. ft ,n k-
Facility/Owner Name Facility ID# if applicable)
ft
tY (� J�
Gd h co( J ft. ft.
Physical Address,City,and Zip ft. ft. Mg I 1 1
,.
ram•x, , _
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe l fiel one laUlon is sufficient) 22.Certification:
29 � N 8d- ! �/Z3 9' w
6ermanent or QlTemporary Signature of Certified Well Contractor Date
.Is(are)the well(s)
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: E3Yes 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 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 if necessary.
drilled: — ® 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 ifdierent(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
Il.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
1 _ 1, above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'CZt 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) G�' Method of test:A'f ?(VJ5'JC— 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
IA.Disinfection type:L'1if q a.r Amount: completion.of well construclirion 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