GW1--04865_Well Construction - GW1_20230728

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
Garrett Clause ;ii14M2iTERZONESW: =='�,'R -=%-:�_=-'_=. s ;'%�'2== �-.�_- ,
FROM TO vDESCRIPTION
Well Contractor Name l ft. 161 ft.
4550-A
ft ft.
NC Well Contractor Certification Number a5FADZBle•ASINGWorliin'1tcasedweIls)ORiL7NERr(ifiprL`cable) ea=1'': •
. Morgan Well & Pump, INC FROM TO DIAMETER
(DIAMETER rTHICKNESS MATERIALy
Company Name (/�,�,/,�(�Q� �J/(��//(� VI' ft `I It a �!g m• J%�t` r V c,,..
`J.��/�+i lYi _i `""�-+ "16'•I1Y1 R CAS'RIGORD$../NGr(ti;e ithecmal;clpsedgtio'p'j,=`, . emu-'`•`;,• `:i�r c;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.r1IC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: .171:S:CILEII!I n`- g,a=-..` ..yam :ts i . t:.:;=tom_.. :_,. =z 1'. .
FROM TO� DIAMETER �SLOTSIZ.E��THICKNESS �� MATERIAL
. Di Agricultural • DMunicipa]/Public ft. ft in.
Q Geothermal(Heating/Cooling Supply) gaesidential Water Supply(single) ft ft in. •
LqIndustrial/Commercial Residential Water Supply(shared) �-_ .,,,� .;,y= .:c-�-: -_-_-:t= ;
�18.,G120bT:v:,u`�"`-'.��t;;�;:; - 41� ��-".:;v'"t�,tr,c=i:,=.";;c.-''�?„��'�.s' '*� �,L���-._'
Irrigation •FROM �TO/�y ~MATERLIAL EMPLACEMENT I ETHOD&AMOUNT
Non-Water Supply Well: . ® ..ft. (J') ft. "-r"r'ia-C__ 'pc)U(ti
Monitoring DRecovery ft ft. '
Injection Well: ft f. t" •
� t .1""?�/6"..�. Rom,
�iAquiferRechazge �GroundwaterRemediation , :, ',._
t19�'S11NIl'/.GRAY.EI„PAG`l�(ifaPPlira'ble�Y'�+"�tl'�,°,=f='�s�3a�.::V".�„si:«-:r :�I:�:r_.
• *Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMErhi,METHOD
NiAquifer Test �IStormwaterDrainage ft ft. �J ✓ d[VZ-3
x]Experimental Technology 0Subsidence Control ft. ft Info;a:" jr:Ti tom, ,;, : j 11
II Geothermal(Closed Loop) ®ITracer ;�20 DRIIS:INGXOG=(alinkr ditio'nai;abeets:f✓ne * YTc aTir-9 "_1t 4 40r
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft TO ft.
. DESCRIP ON(ebb!,he�s,soillrocktype,grain size,etc)
, 6'Z y ,r
•
4.Date Well(s)Completed: Well ID# ft b ft f 0L� t1,r'
5a.Well Location: • p ft. 6Qa ft �(ry��,�l^ �Y(N
� v Gk. 3S -J ft. v a ft 5 GIN) S )& v
Facility/Owner Name Facility ID#(if applicable) 7O ft 125-- ft / 1( iti
ZGi l k/1a.1& . aGr\, V.0 Sees vie1 1 of ft 'too
it. VAAL if 9_I 1/Yt\
Physical Address,City,and Zip ft ft
iieJ A\. tint,qcI- 'Lg'So ..dPnREIVIAIIiS,,:_.Fri ..r..__.. r.:'li•liVi r_.:.Y; : _ 4-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well ld,one lat/long is sufficient) . 22.Certification:
SS 1' L ) N 6 7s 'Ll w .c J, 1,613
6.Is(are)the well(s) Permanent or �ITemporary 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 existing well: IDYes or 1No 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: 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 dderent(example-3@200'pnd 2@100) construction to the following:
10.Static water level below top of casing: [Jl►p" (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: OP ii(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
]l ��t • above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable;direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: " 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) r— Method of test:-
r ?Cep`'(r— 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'1,r"a A 0l e.0 Amount: 8'&Z 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