GW1--04228_Well Construction - GW1_20230706

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause rFla-scxzois 2.,1. -
-_-
:..=.... -..r W..._.4i.ram':._.:, .v;i,..., ,ir
FROM TO DESCRIPTION:Well Contractor Name • ft ft. i
4550-A - ft ft
NC Well Contractor Certification Number 0.5 ©,I`I•ER CASING(forma'lficased wells}OR3INER$(if sp°•Lcable) '
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft %0 ft f� yg =n s%%t\ ` V C
Company Name \L. K]
y �(C AKINNERC-ASINOltIt Ul3ING.reotfierinnl-r"I.oseedgoop <;� ..ate„ -' ='
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. en.
ft ft in
3.Well Use(check well use):
,m.
Water Supply Well:1 =.1T:S.GREEN= a '; -r= ._ _<-ti<_ _._dam__ <_
FROM TO DIAMETER SLOT SIZE T=CIINESS MATERIAL
Agricultural DMunicipal/Public ft. ft in.
in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft.
Industrial/CommercialResidential Water Supply(shared) id8 GROTY a...; ::_ -> ` '"5`t --5 0s-= z - P43:<( ''
Irrigation FROM �TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: . O ..ft (J") ft ,,115„i,}-C_- pUurej
IIIIMonitoring DRecovery ft. ft
Injection Well: ft. ft.
**Aquifer Recharge D Groundwater Remediation ,..9.', ,
.;_1SAND/GRAV.EI ACg(i[applicable) .--.....,r1 e.1s.r .i*
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test DStormwater Drainage ft ft.
1 Experimental Technology DSubsidence Control it ft. e^ ,a e yri.�r„)
*Geothermal(Closed Loop) QlTracer g2,01;DItIIiI.IlNGZOG=(attaiad Elditi'o'usl:e`heetscif-necessa ry) i,;% �___ "r..k..m4)
FROM TO DESCRIPTION(color,hardness,soil/Topictype,Brain size etc.)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Oft �- ft. gee) h I— Jut-- 0 6 2023
4.Date Well(s)Completed:6"'5-�Z3 Well ID# ft /0 ft Q� Virkmh,;,;--..wCn �r
/(� ft. ��(� ft. VVS�J ti:l,riQ' ^r. ` (:r
5a.Well Location: 1 �( t 1 / y J �4�
�"� 1 1A ) , �; l V Y� ft. ft. 56��; Sto�
Facility/Owner Name Facility ID#(if applicable) q6 ft 2 ft. slot/ G Ff�
1115 se0'78- iS1-41 cs C- r Sal;S.�,r , 2 ft Y ft p.,s(�.�w t y rail;Ant
Physi al Address,
City,and Zip `�'`��9 ft ft. =
CO"V L[ (9 Z V V s#21'IRF.MAIIKS",'. :`.fiL.,.."., r=IR,..:_r0_ '.f;-t-;';=
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if w el one lat/long7is sufficient) 1 22.Certification: �j'�
› T75W N ga q7o\c W UA C - ` .
6.Is(are)the well(s)MPermanent or DTemporary Signature of Certified Well Contractor . mate
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or CKNo with 15ANCAC 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 22@11'0�0) construction to the following:
d2 •
10.Static water level below top of casing: C (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 Infection Wells: In addition to sending the form to the address in 24a
(-0 C�4'r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable;direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) (0 Method of test:.-4(( ?CVO're - 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:GC it u(6..( Amount: 1-C'2 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