GW1--03853_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Garrett Clause 14 FSrTERZOPTEs�t, _ r � -
FROM TO ,L DESCRIPTIONL
WellCo�cactorName ft. it
I
4550-A ft ft
NC Well Contractor CertificationNumber
°;15�_OLISSERCASINGrformnllicasel�yells-QRlttit%a"'liable'a-='%=;�';•.�=:1 -::
Morgan Well &Pump, INC >ROM To DIAMETER TMCIMSS MATERrAL
ft aft in. '(, IPVC
O e�6�IlwrmCMNRM eobmi=cloe-0Co anyName '
2.Well Construction Permit
TE _„
FROM TO DIAMETER TffiCI4dE55 `MATERIAL
List all applicable well construction p its(11.e.VIC,County,State,Variance,etc) ft ft �
3.Well Use(check well use): ft ft
`
Water Supply •1T:S.CREEI�I:�� "-_-`��•s,����^
PP Y Well: FROM I TO F I DIAMETER SLOT SIZE TE IC4ESS -MATERIAL y
i Agricultural OMunicipal/Public ft ft in
_i Geothermal(Heating/Cooling Supply) Resjtllenti3l a S:?PP n ft ft. in.
Industrial/Commercial ri Residential Water S pply'(s ared) Y18.GIFODT:: : - _ 7a f-
Irri ation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
NNon-Water
Supply WeH: ` IN "ft ft +&A i V v�'
Monitoring DRecovery,_; ( R i ft ft
Injection Well: OU'SQi ft ft
iji Agtufer Recharge n Groundwater Remediation F t -_�;,,.-,: r.:..., �i.r r --
F 19:'SAND'/GRAVEL Pi�iG> tf applicable`_ ._ _ z .- = ='_
I Aquifer Storage and Recovery ©I Salinity Barrier FROM To MATERIAL EMPLACEMENTMETEOD
Aquifer Test DStormwater Drainage ft ft
I Experimental TechnologySubsidence Control ft. ft
Geothermal(Closed Loop) ®_I(Tracer =20; I2ILLIlVG OG attach a`daifiorial;sheets�ecc+--- �r�' O J;—z:
-FROM TO DESCRIP ON color,hardness,soil/rock e, -grainsize,etc.)r
.I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) v ft ft ,r
4.Date WeIl(s)Completed: '�Well 1D# ft Q ft 0-cW4 �,14-
5a.Well Location: ft p ft o r f"CL(,L_
�C!j C
Facility/Owner ame Facility]D#(if ap licable) ft ft
126 vex 'hyso� ft ft
Physical Address,C. ,and Zip f'�] ft ft - -
C67 RE111AZ2K3,..t. _z
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if ell one lat/long is sufficient) 22.Certification:
NO.tO 5 � W
6.Is(are)the well(s) ermanent or OTemporary Signature of�Certi�fie`d'WellContractor Dat
By signing this form,I hereby certify that the well fs)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or ENo 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 NUNIBER of wells construction details. You may also attach additional pages if necessary.
drilled U SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of wen
For multiple wells list all depths if different(example-3@200 f 2@100) construction to the following:
10.Static water level below top of casing: (it) 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: TL Vt�,'r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WY: II 1636 Mail Service Center,Raleigh,NC 27699-1636
ELLS ONLY:
13a.Yield(gpm) q Method oftest:Ar ?CV-LA1F-- 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
IA.Disinfection type:GirdgAw aC Amount: t" completion•of well construction to the(county health department of the county
where ponstructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016