GW1--03237_Well Construction - GW1_20230511

�PrI. t Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause i4waTERzoNEs
FROM TO DESCRIPTION
Well Contractor Name qf. ft.
4550-A I ft. L_I ft.
NC Well Contractor Certification Number """ -
15 OUTER'C-ASING fdrmnitLoased;.w"ells OR`IINER�ifa '
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
it ft in. V C
Company Name t
I,,��/�U�]��/+�/'y��� 16:t'INNEFi.GASING:OR TIIBING: etittiermal'cIo`sed Ioo
2.Well Construction Permit#: '(�r/ l/�.- -(/ V '�•'�lJ FROM TO DIAMETER TffiCRNEss MATERIAL
List all applicable well construction permits�.e.TM,County,State,Variance,etc.) ft• ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:1 F7::S.CREEN -
FROM I TO _. DIAMETER I3LOTSI7,E THICKNESS .�MATERIAL ,•
J Agricultural ❑MunicipaltPublic ft. ft in.
r!Geothermal(Heating/Cooling Supply) !I esidential Water Supply(single) g• ft.
IndustriaVCommercial DResidential Water Supply(shared) 18 GROIIT - -
J IIIl atlOn FROM TO~ . ...MATERIAL.; :EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: ..ft. ft U��
[,Monitoring DRecovery ft ft.
Injection Well: ft ft
�'Aquifer Recharge D Groundwater Remediation
SAND%GRAV:EL;PACK•:if
Aquifer Storage and Recovery Salinity Barrier FROM TO MATEIIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage
J Experimental Technology E3 Subsidence Control it. ft,
r'Geothermal(Closed Loop) ❑J-(Tracer :20 DRILLING:(OG'a[tachaddrhorial.sheets'ifn&cess
Geothermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sail/rock e, size,etc.
--- ft. ft
4.Date Well(s)Completed: Well ID# d ft. 1 ft
15� it
Sa.Well Location: O ft. 4/ ;
M c1.el lb NO it vit. ue gt�„ 1L
acility/Owner Name Facility ID#(if applicable) ?�ft. ft. III
Y
g�13 -4oyerY2o� "�6'w;t Cal co it. it.
ft. ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ielld,one lattlong is sufficient) 22.Certification:
/7/9co .70 N W A / e� �; Y�1 L
6.Is(are)the well(s) ermanent or []Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(y)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JXNo 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 additiopal 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 if different(example-3@200'annd 2@100) construction to the following:
10.Static water level below top of casing: qG (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 Iniection Wells: In addition to sending the form to the address in 24a
Ito above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: S construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: JJ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test•A'r �(��`�Imo— 24c.For Water Supply&Iniection Wells: In addition to sending the form to
pp** Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:G r4 ii 1 64' Amount: completion.of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016