GW1--03317_Well Construction - GW1_20230512

Print-Forni WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause .14 WvkTFILZONEs `
OM TO DESCRIPTION
Well Contractor Name ., Vft ft
4550-A ft ft
!
NC Well Contractor Certification Number
15OUSER:GASINGforinulh�caseitwells OR"LINER'd�a hcable '=� "'�
Morgan Well &Pump, INC FROM To DIAMETER THICffiVESS MATERIAL
ft ft in. vL VC
Company Name �f _ -
l.(d 1'G`INNER:CABIN •AR:TQBING. 'eothermahclosed loo
2.Well Construction Permit#: FROM To DIAMET ER TffiCKNESS MA'rFRrnr.
LW all applicable well construction permits(:.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft % in.
1 :17::StrREEN ._:
Water Su
PP Y Well: FROM TO I DIAMETERA SLOT SIZE THICKNESS MATERLAL
Agricultural []MunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft. ft
_!Iudustrial/Commercial !Residential Water Supply shared
PP Y(shared) ;18.GROUT
J hri ation FROM TO MATERIAL EMPLACEMENT NMTHOD&AMOUNT
Non-Water Supply Well: ft. ft �•pA U u(e
r'!Monitoring DRecovery ft. ft.
Injection Well: ft ft
=I Aquifer Recharge 1.=J Groundwater Remediation
19-SAND/G12AVFhYACK`.rf-appI cable :•
I_'Aquifer Storage and Recovery !�IJ Salinity Barrier FROM To MATERIAL EMeLACEMENTA=OD
:_]Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20:DRILL'IlYG'LOG attacli:addrhonal'.9heets iEnecess
!Geothermal(Heating/Cooling Return) :J Other(explain under#21 Remarks) I
FROM To DE TION(color,hardness sod/rock e, size,etc.)
0 ft. ft. I
4.Date Well(s)Completed: (`{ 4 w Well 1D# (U ft () ft
Sa.Well Location: ft ft.
�,✓ ft. ft
Facility/Owner Name Facili lD##(if applicable)\ ft
'�` ft. ft. `+s+p. ...t a �....✓
P cal Address,City,and Zip ft ft 7-023
County Parcel Identification No.(PIIN) 1?f^ t. t'O^
G4aL}�a�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiJeId latllong is sufficient)S ^/ �� � 22.Certification:N <bj o� 3� W
6.Is(are)the wll(s) ermanent or OTemporary Signature of Certified Well Contractor a
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 Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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 ofthis 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: /`-'y 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 2/@I 0D construction to the following:
10.Static water level below top of casing: (/ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ftoS`` above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 7 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: /I 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) is Method of test:A' q7 r �( (VJL�1 r-- 24c.For Water Suunly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one,
3b copy of this form within 30 days of
1 .Disinfection type:�'itf''i A A 4C Amount: 8 completion.of well construction to th'e 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