GW1--03315_Well Construction - GW1_20230512

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WELL CONSTRUCTION RECORD (GW-1) or Internal Use Only:
1.Well Contractor Information:
Garrett Clause
FROM TO DESCRIPTION
Well Contractor Name ft ft
4550-A ft ft
NC Well Contractor Certification Number ml'S OUIE1t C9SING formiilfcase3�sells OR�LILVER3 hcable va
Morgan Well &Pump, INC FROM TO DIAMETER THICI{NESS MATERIAL
it 155 ft in. ?VC
Company Name ('�� ('l 16'1=IIVNEI2.Ce1$IIVGOR;TQBING' eoerma7-closedlooti -
2.Well Construction Permit#:'[AU- `�f�6DO001 � FROM TO DIAMETER 'rHI Ss MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft in.
ft
3.Well Use(check well use): ft in.
>173:S.CREEN:
Water Supply
Well FROM TO DIAMETER SLOTSIZE~ THICKNESS MATERIAL
Agricultural PMunicipal/Public ft. ft in.
i i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
Residential Water Supply shared
I I Industrial/Commercial � PP Y(shared) ;�8`�GRObT3;:`a?;� _ �_ -''�-�� =-`-;:. �-•,- ��.. -;;='v,`:.:
Irrigation FROM TO-� I MATERIAL= ~,EMPLACEMENT TROD&AMOUNT-
Non-Water Supply Well: ft ft
E.Monitoring oRecovery ft. ft.
Injection Well: ft ft
Aq suifer Recharge Groundwater Remediation .
19.-S AND
/.GRAVEL-2'ACg>£a"`licable s r 3:
—I Aquifer Storage and Recovery J Salinity Barrier FROM I TO MATERT41 ~~EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft
J Experimental Technology 1 Subsidence Control ft. ft
Geothermal(Closed Loop) [_I Tracer O;:DRIIIIlVGDOG;atfaclradfionaLsh`eetsif neceas'a" i ;; :n;_ -=-_ l''z== -
FROI TO DEsCRIPTIO q(Colo hardness,soillrock type,--pmin`•size,•etr-)s4~
_I Geothermal(Heating/Cooling Return) U Other(explain under#21 Remarks) ft b ft
�-
4.Date Well(s)Completed: Well ID#
52.Well Location: it ft `ry„
ft. ft
ft ft ty !
Facility/Owner
��Name Facility ID#(if applicable)
� J ti�'-�L Z `tr
Ph y' l�Address,City and Zip ^ !1 ft ft r
C/i� J`J` i21'tRE1GIABKS'= '-_fix:,';; :: ,"J;
Coun Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lFatllong is sufficient) O U /a / 22.Certification:
'?7q N 9p, W "�'4
6.Is(are)the well(s) Permanent or OTemporary
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 existing well: MY es or CKNo 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: •� 1 / SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: w"' (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'an `000) construction to the following:
10.Static water level below top of casing: v (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
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,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) <1 Method of test:Ar ?M-Lf�-I— 24c.For Water Supply&Injection Wells: In addition'to sending the form to
�i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C'� r-q r7 d�ae Amount: \,� V 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