GW1--03832_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause ?3-1 �Y TERZONES ._,s_ 't 4 s
FROM TO DESCRIPTION
Well Contractor Name ft. ft
4550-A
ft ft.
NC Well Contractor Certification Number - -�
15%_O17SERCASI3VG'formn'ltcased•�yells'OR7lnVER
Morgan Well & Pump, INC FROM TO DremMET R! THICKNESS MATERIAL
it ft in. V C,
Company Name ���� 3'63iVPIER:C9STNG' RIIBIIHG: eothermal;clpsed�oo _x^
2.Well Construction Permit#: FROM TO DLIMETER I TEaCKNESS I MATERIAL
List all applicable well construction permits C.e.VIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): nnfft l ft in. r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS~ ^MATERLII ~
Agricultural El Municipal/Public ft. ft in.
_i Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) R ft. in.
I Industrial/Commercial DResidential Water Supply(shared) _
PP >18 GRObT:r.:
I IIrl atlOn FROM TO r MATERIAL EMPLACEMENT THOD&AMOIINT
Non-Water Supply Well: ft ft +6"1 Uv f.e
Monitoring DJ Recovery ft ft
Injection Well: ft ft
_1 Aquifer Recharge Groundwater Remediation �19:.6AND/GRe1VEL ACK°i[a hcable; _ �r�,: . ... z .•ws_ ti-t
I Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLA MESHO
I Aquifer Test nStormwater Drainage ft ft `' 4
I Experimental Technology I-1 Subsidence Control ft. ft +10lP/1^.7ii�i1 �f�ti;a!lv3s`Fi! t
Geothermal(Closed Loop) ©J ITracer �,2Q::DItILI:IIVGOG=atlacIradditiunal;§heats it neceasar_` .;
J Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillmck a size eta
G ft. cJt f
4.Date Well Gs)Completed: ��-`� Well ID# c7 ft ft CA/
S{ In(Ik
a.Well Location: ,, ft t
7v fO y, le"ye-r �B ft. l2D ft
Y
Facilitya/Owner Name { FacilityID#(ifapplicable) O ft p ft
,3 1 q '-f�'�cr f ar 4.nj ua ft
Physical Address,City,and Zip ft ft
G-aG�
r2��,(,�S 21REMr1RKS;`' -_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/long is sufficient)� 22.Certification:
Q�N U O.(�/'-3 �0.y w ' e{y Cl L)
ant Tem or Signature of Certified Well Contractor Date
6.Is(are)the well(s) e rman or p ary
By signing this form,I hereby certify that the weIlfs)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ENo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fdl 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 thisform. 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 qzo
of wells construction details. You may also attach additional pages if necessary.
drilled: I. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi#erent(example-3@2 00'and 2@100D construction to the following:
10.Static water level below top of casing: Division
(ft) 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 Injection 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: fL V-C"f 7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL�Yf WELLS ONLY: JJ {� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `^ Method of test:A'r [ ���'I-- 24c.For Water Supply&Injection 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:C.'I,r'4 on 6-T Amount: 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