GW1--03827_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Garrett Clause -::ram -•. 'c' ' v ` =n
f 14::F�'$1 EILZONES a s v_r,...c_
OM TO `DESCRIPTION i
Well Contractor Name V ft, it.
4550-A ft ft
NC Well Contractor Certification Number r. v - �.. -.-t__ .... ..,_ — :.,_ .-r...-•.:.
;�15 O71•ERrG�SING;formn"Iteasedsryells:ORIIINERz 3f%a Leable'' =Y-��- :-tc:_s:: '
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft ft in. V C
CampanyName ��+J ^ _1G ILVNFER:CA�STIITGOIL:T[IBIPIG// eother'malosedgiio
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.VIC,County,State,Variance,etc.)
ft ft in.
ft ft �•
3.Well Use(check well use):
�
W 7
water Supply Well: FROM TO~. DIAMETER SLOT SIZE i3xTHICKNESS Y-� MATERIAL
I Agricultural []Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
Industria]/Commercial Residential Water Supply(shared) ZBGROUTar-�_ s"•'=r= 1 r -Irrigation FROM I TO MATERIAL EMPLACEMENT THOD&AMOUNT^
Non-Water Supply Well: ft- ft
( Monitoring nJ Recovery ft ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediatioa 9'SANlGIAf5
r$a Ircalile. aM y`
I I Aquifer Storage and Recovery E3SalinityBarrier FROM I TO MATERIAL EMeLACEMENTMETHOD
I Aquifer Test !Stormwater Drainage ft ft
I Experimental Technology []Subsidence Control it ft
'
Geothermal(Closed Loop) E3Tracer g_20;5RMMNG%OG=atiac'Ti'a`dditi`onal: ifneceas" 'f': ='•. _ ' ?
}size,etc.&
I Geothermal(Heating/CoolingJ�Return) ? Other(explain under#21 Remarks)j
FROM TO DESCRIPTION(color,hardness,soilirockc_1/ ft Zy ft .r
4.Date Well(s)Completed:," 26 2J Well ID# ft
ft ap ft �/ {
5a.Well Location: 1 f 1p
(�CI�'hl/►['L..� �in.%(� "f�rvSk _ orb ft J't-t t
ft ft
Facility/Owner Name Facility ID#(if applicable) �`+•
7775- 661rVice-, LlL -5:1isk'rl/ ft ft
ft ft
Physical Address,City,and Zip _ __
�iEn�ARxs;'7'. =_ =' r= =_ y.. _r,•_ ,,:5..
L rsx
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
�lat/lonnygis sufficient) �rp��� 22.Certification: n�
�5�l7 ! L� N 9G•yb0"6 W �T'1G Lb �i
6.Is(are)the wells) ermaneut or E3Temporary
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: OYes or 0(]No with 15ANCAC 02C.0100 or 15ANCAC 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 ofthis form. 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: SUBA=AL INSTRUCTIONS
9.Total well depth below land surface: 5�0 a (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D 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 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
1 _R above, also submit one copy of this form within 30 days of completion of well
'C
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 PLS ONLY: / �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L(y/ Method of test:A'f �[ CVO'r-- 24c.For Water Supply&Injection Wells: In addition to sending the form to
//++k the address(es) above, also submit one copy of this form within 30 days of
3b 1 .Disinfection type:G1 l n A QC Amount: (b//' � 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