GW1--03336_Well Construction - GW1_20230512

!: Print_.Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause a.wATERzolvEs -_
Well Contractor Name O O DESCRIPTION
�, ft. ft
4550-A
ft ft
NC Well Contractor Certification Number
15.;OLiTEH:CASING f6i. lticasedwells OR•I
Morgan Well & Pump, INC FROM T DIAMETER I THICKNESS &MATER
ftYb ft la Y9 in. V
Company Name _
��� .16sINNER:CASING:OIi:TIIBING` eotlieiaial'do'sedloo _ _:__.._ - -
2.Well Construction Permit#: FROM I To I DIAMETER I THICKNESS I 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.
Water Supply Well: FROM ,..;:L
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIA L
Agricultural DMunicipal/Public ft. It.
in
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: it. ft. f4e ,hpn i U u
r Monitoring DRecovery it ft.
Injection Well:
ft ft
7 Aquifer Recharge L_i Groundwater Remediation
_ 19 SAND/GRAKEI:PACK'.i€a livable_ .
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test =I Stormwater Drainage ft. ft
JI Experimental Technology DSubsidence Control % ft
Tracer g20:i1)I2ILIIl�TG:LOG attachaddttiorisl_s`heetsifiii e—
I Geothermal(Closed Loop) QI - ..a. -- �.. -,• -
:]Geothermal(Heating/Cooling Retain) [f Other(explain under#21 Remarks) ft. ft
FROM T D CRIPTION(color,hardness,soil/rock a in size etc.
4.Date Wells)Completed: [ ..I')'�3 Well ID# it ft. ftu_m V,SV
5a.Well Location: ¢� tft-f sc-na S by
tlS ft. ft
r
Facility/Owner Name Facility ID#(if applicable) "®ft Go-
ft.
�`t 5' /UC 12_ /-CWY J'K3\\ ?ltic 14A\ 62 ft ® ft-
PhysicalZip
t
Ph sical Address,City, ft. ft b y
Y .and Zi P
County Parcel Identification No.�S 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :-
(ifwelll field,one
ellaat/longgjis sufficient) 22.Certification:
N Q)�. W
6.Is(are)the well(s)'Permanent , or OTemporary Signature of Certified Well Contractor Date
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: DYes 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 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: .I_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `2 3C' (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000''an`d 2@100D construction to the following:
10.Static water level below top of casing: w (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: S 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: II 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,6 Method of test:Af�f V-V1Jr-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�+ n the address(es)'above, also submit one'copy of this form within 30 days of
13b.Disinfection type:L64 n v1 6.0 Amount: (n completion-of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016