GW1--03899_Well Construction - GW1_20230609

=�'� r1nt,Form=
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Garrett Clause
FROM TO DESCRIPTION
Well Contractor Name ft ft
4550-A
ft ft ,
NC Well Contractor Certification Number 15.i0U ER"CASING'furmnit case8 v ells ORTINERt ifn"Lczble i` -
Morgan Well &Pump, INC FROM T DIAMETER TffiCIQQESS MATERIAL
/\1 //� ft. (�ft in. VC,
P Y '� d V VV"��`���� �p
Com an Name //�/(� I ;�'G 36 1NNER CtiSINGbR T[TBING eotliermala6sed2oo
2.Well Construction Permit#: �,r "LL V U FROM TO DiAMFTRR THICIQ�SS v~ MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft 1n
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROMI2EE T yam:- _•n'm
PPY FROM TO DIAMETER SLOTSI21:� THICIQVESS MATERIAL-�-
I Agricultural DMunicipal/Public ft I ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft in.
Industrial/Commercial J Residential Water Supply(shared)
I Irrigation FROM TO. I'-MATERIAL; 'EMPLACEMENT THOD&AMODNT
Non-Water Supply Well: ft ft r V v
MMonitoring [Recovery ft ft.
Injection Well: ft ft
__Aquifer Recharge —i Groundwater Remediation
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test �II Stormwater Drainage ft ft
]Experimental Technology IOSubsidence Control ft. ft
Geothermal(Closed Loop) E3Tracer S2o%DR]LtiING OG=atfaciladaifiurial�hee'ls ifneceas r: `t°:tl`=_ '1 '
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) I
FROM TO DES TION(color hardness,soil/rock grain size,etc
t ft I r
4.Date Well(s)Completed: L�'23 •Well EM ft ft t5o
5a.Well Location:
_?cs r�dn ft. 2?�t
Faac'iflit�yl/`OwwnerName Facility ID#(if applicable) ft �t't e ([-/ 5 ram,%
"l 0/( ✓Na``Crd:� eR D "�Jz"A �/_ ZSft rn c atn%!r`L-
Physical Address,City,
and Zip I ft Uv
County Parcel Identification No.(PIN) 91 • `L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,.,.,�t1 ,!9y
(ifwellfield,onelat/longis sufficient) Q� 22.Certification: �Mnia' Wcn Rro-3i3t�.JJrA
N U / �1�z W G7'sPKlt
6.Is(are)the well(s)myerntanent 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 e3isting well: Dyes or D(No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 T7ell Construction Standards and that a
Ijthis 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 additional well details:
S.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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: �\ SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: V (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200' d 2@I00) construction to the following:
10.Static water level below top of casing: (fL) 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
Va `! above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY XLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A f_ 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:G'1,f Q n��Q� Amount � V 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