GW1--03233_Well Construction - GW1_20230511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause 14 wATEIzolvEs -
OM TO DESCRIPTION
Well Contractor Name ft. ft
4550-A ft. ft.
NC Well Contractor Certification Number
IS:OUTER;CASING'for.ninitLcased_v7ells ORa+IINER�ifa'hcable ;'=- -.-.
Morgan Well & Pump, INC FROM TO DLAMETER THICKNESS MATERIAL
ft.
ft `� V C,
Company Name
-HA—w�ge�^�oa„` �� 16IMNER.CASING:OR;TIIBI M eatliermalcTo`C10Eo
2.Well Construction Permit#: f�►/ (.L FROM To DIAMETER 'rHICIa1Ess MATERIAL
List all applicable well construction permits(ii.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural —1 Municipal/Public ft. ft in.
Geothermal(Heating/Coohng Supply) residential Water Supply(single) ft. ft.
_D7 industriaUCommercial DlResidontial Water Supply(shared) ;.1B::GROUT
—!Irri ation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: it. ft t V v
Monitoring DRecovery ft. ft.
Injection Well: _ ft. ft.
Aquifer Recharge Groundwater Remediation
_`L1R.SAND/GRAVX a"`livable _ "
I_:Aquifer Storage and Recovery E3SalinityBarrier FROM To MATERIAL EAU EMENT METHOD.
:[Aquifer Test [3Stormwater Drainage ft. ft.
—!Experimental Technology ©ISubsidence Control ft. ft.
Geothermal(Closed Loop) iJ Tracer 20.;DRILLING'LOG attach'addihonaL`sh'6 6 if.necess ': r
FROM TO DESCRIPTION(color,hardness soiltrock type,pain sae,etc
_i Geothermal(Heating/Cooling Return) J Other(explain under 921 Remarks)
4.Date Well(s)Completed: Y'b—Z� Well ID# rft. ft
5a.Well Location: So it. O ft-
Facility/Owner
`ion�U �-,�►��,� U ft. �,,
/ Namel-@ Facility ID#(if applicable) ft. ft.
f �I V' �rt l lsb ft. ft r. ^� "g"
Phys'ill Address,City,and Zip
ft ft
21rRE1144:RKS
..1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaU\longg is sufficient) q 22.Certification:
is
� 1 /O NCB_ `�d� W
6.Is(are)the well(s) ermaneut or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerhjy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or D�No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: qG (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
r construction to the following:12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: // 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `" Method of test:A'r ���`' 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:Gc-A A-[64' Amount: �a� completion of well construction to the county health department of the county
where consstructed..
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016