GW1--03907_Well Construction - GW1_20230609

• =Ptitit�Form:__'
• WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Garrett Clause fiIa.: :%ExzoNEs� , w i r-. '„g..r- : z
Well Contractor Name
4550-A •
OM TO DESCRIPTION
�� ft. ��\ ft.
/ ft. ft
NC Well Contractor Certification Number g Fx' "'i ry•--' '.. 3 �' ''
..15:U_T72'ER-:C>ASILVGi(fo"rmultcasedgiyell7.OItTINER.(ifiip"licalile)=,�:.���t;,,` ;=:
Morgan Well & Pump, INC FROM TO' s DIAMETER THICKNESS MATERIAL
ft u v1 ft /� yg in. s pl1,\ P V c
Company Name r u i Ai _(�y+y� /t 7G'INNER C lr1SINC OR3lJ'1SOlNJG(geotlieimal e osed7oojr • r%c.
2.Well Construction Permit#:L,r 1��• ������ "`'��'Iv FROM TO DIAMETER THICKNESS 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.
i<X?S:S:CREEI`Ii ' -`��:_ y`_=;< •���'x �: `_- :. �`='~-=-_-. .=:.;=_':':�:tFaa
Water Supply Well: FROM TO DIAMETER SLOT SI2E� THICENESS MATERIAL '
Agricultural Ijj Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) jr' (Residential Water Supply(single) ft ft. in
Industrial/Commercial _i Residential Water Supply(shared) - w^1 - __ :r<=_=t=_ _ _ - _5
Irrigation. FROM TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . 0 ..ft ' ft fervi-prii,}-e__,. pUure3
Monitoring Recovery ft ft.
Injection Well: ft. ft
Aquifer Recharge t'_'r Groundwater Remediation , u` fi ,y
_19.'S A lD/G]tA VEIPACli`(it:applicble), .a.
• E Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DI Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Ill Subsidence Control ft. ft. •
Geothermal(Closed Loop) EllTracer r}20:-.ill. ING; OG;-attacli7addifinnalihee`ts neceasaiy-W, `= <.:!:M=A
Geothermaleatln Coolie Return) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
(H g/ g Other(explain under#21 Remarks) b ft . ft \ k
,
4.Date Well(s)Completed:S Q aeld) Well ID# . ft ft /$(6,111r \`)y(V
• tb) ft `1 ft (b-
SaWellLocation: ` \U�/ (�`
1\VOl`I V e %L'l�b/ c.V rS ft. ft. (3 (. Kv .
acili /Owner Name //��' Facili ID#(if applicable) Vecs V it
1S ft "\\C1- c k�
565 Y `\Ck4 c Kr`\ Nf,�((sShUI ft �7 ft ,.
Physical ddress,City,and Zip ft ft i - . -� f. r
�+�.%r�' p r '�, :'lPiiIIF.MARK.S., .:��. —it4,t ati.'` ,?: :�=:r.. '5'14:..1 =:� =�'.`t=:,-
County Jl Parcel Identification No.(PIN) JUNto 4 )f I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well)5 ld/one laU ~long is sufficient) �\U G 22.Certification: :�
22
J\�'1� N l�t w 14�• 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 wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0I Yes or )►j;'No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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:
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: 1-• SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �c ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (.1 (f-) 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: s,,(in-) 24b.For Infection 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: I1 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: // {7 ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) \% Method of test:."{(( •T ( ''fc— 24c.For Water Supply&Injection Wells: In addition to sending the form to
(C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:a ei n u4 6.f Amount: 1 . 61, 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