GW1--03302_Well Construction - GW1_20230512

P' t Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Garrett Clause - CWAxERz0NE9
FROM TO DESCRIPTION -
j
Well Contractor Name .,
4550-A
ft. ft
NC Well Contractor Certification Number if -
AVlER•GASING.formnittcased:wells ORLINER' i"'livable -
= r
Morgan Well &Pump, INC FROM TO DIAMETER THICIINESS MATERLAL
ft. ft. in V
Company Name I do rtj q
`16INNER°CASING:OR;T[JBING'eothermalelosedloo _Ks. - ,._
2.Well Construction Permit#: FROM TO DIAMETER TrnclavEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
LLultural
Supply Well:
FROM TO DIAMETER SLOT SIZE TBICMSS MATERL4L
Municipal/Public ft ft. in.
ermal(Heating/Cooling Supply) esrdential Water Supply(single) ft. ft intrial/Commercial Residential Water Supply(shared) :.-I_,GROUT
tion FROM TO MATERIAL EMPLACEMENT XMTHOD&AMOUNT
Non-Water Supply Well:
t.
G Monitoring DRecovery 6 ft. c, ft- K z.A t V
Injection Well:
_ ft ft
( 'Aquifer Recharge Groundwater Remediation
19 SAND%GRA%Tt_?ACK rf=a"`livable ,
_I Aquifer Storage and Recovery DSallnity Barrier FROM TO MATERIAL FMLAMAENT METHOD j
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 1 Subsidence Control ft. ft
_'Geothermal(Closed Loop) U Tracer 4.-IUDRILLING TOG.attarli'additional'sbeets rfnecess r
Geothermal(Heating/Cooling Return) IJ Other(explain under#21 Remarks) FROM TO DESC TION color,hardness,soli k e, size,etc.)
- ft. ft.
L
4.Date Well(s)Completed: q_y6 Well ID# ft 6b ft S-CIWA t,r
5a.Well Location: 6d ft. ft. %ktk t6u
117�-Sus Al�c,.,�eZ ft 15 ft. `fir.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip
• ft. ft.
�,.. a..- ...�
k[en
County U Parcel Identification No.(PIN)
ifl�irfi"=- _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�l SS fi�1d,one]atf1mig is sufficient) Q 22.Certification:
C/J1 op N 2L W 'f l lol
6.Is('re)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify' that the wells)was(were)constructed in accordance
7.Is this a repair to an effisting well: E)Yes 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additio7nal 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'and 22Ca 100) construction to the following:
10.Static water level below top of casing: Z v}3 (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 Infection Wells: In addition to sending the form to the address in 24a
kv r 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,directpusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: II �y 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test:Af S ��`''�- 24c.For Water Supply&Iniection 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:G'ra n-1 o.r Amount: 6 C) L-. completion of well construction 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