GW1--05740_Well Construction - GW1_20230905

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• WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
,
I.Well Contractor Information: G
Garrett Clause tidy TF7i.7.n1VFlS:a-0,Y,' 3: :*>:'>:i.�.�.::`:'., `s ;* s' ." '.'', .tr..=>
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Well Contractor Name FROO DESCRIPTION I
.. ill Sft I c ft. 1
4550-A
ft. ft.
NC Well Contractor CertificationNumber ,�6.4- • -g -....,_ .,..�i - r.k „g M�,�„
Nl��•SOOT]`fERCASING:(form'ltcssed�i9ella)QR�TI11'£�Rt(ifaP,leable)-s�Y=z �•a:>. '
. Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft `\q ft fi yg in. S PUL\ PVC,
Company Name __
CAS G1 c 23- I�11 11 O d:0=.. 011N G:4etitherm seagbV15) `i gaVR1142.1f.'3i is
-r2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIALe
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.
Water Supply Well: 'i'al:S:CREENy. �.-5=•`.:�_ t a;:-x'% _1t<'1SU AliMda"'�:v`-:`?c_�?': ':`:£SI;s n .
FROM TO _ DIAMETER SLOT SIZE THICKNESS .MATERIAL
Lt Agricultural DMunicipal/Public ft. ft in.
rir Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
*Industrial/Commercial DResidential Water Supply(shared) .�; :z i_ ,.-; •:--;F, : 7 _. _- ;:_+ •^F «':r; ; .
s�$::GROET:a- �:S=ram_.. -_��%sc"e �:�- �eo_ c��>'�:�.
;Irrigation FROM TO MATERIAL EMPLACEMENT NETHOD&AMOUNT
Non-Water Supply Well: ' 0 ..ft eip ft.. i pV u reJ
Monitoring nRecovery ft ft.
Injection Well: ft. ft
Ni Aquifer Recharge D Groundwater Remediation - .
itigS`A14D/GR`AV.EL'aE'A6`gragliliablel;,,I �` ;„:o.,.-z*=• lath' ; c_'ystzi `s::
• **Aquifer Storage and Recovery ©I Salinity Barrier _FROM TO MATERIAL EMPLACEMENT METHOD
MI Aquifer Test D Stormwater Drainage ft ft
1 Experimental Technology IDSubsidence Control ft ft. •
tiGeothermal(Closed Loop) ®ITracer :LO>Zi1tIaIIGXGG:(atlaslraadifibnal;s`heefaaeceasafyj t;.^ 4 . .?r-`: *ii ' -. '
_I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO D CRIPTION(color,hardness,soil/rock type grain size,etc.)
G ft. LG ft- . 1(�C" ;Welt"
4.Date Well(s)Completed: -2��2� Well ID# (Li' ft 4 a ft sa ru, t t�-
Staa..Well Location: 6 Ca ft )o�'?t S G ktock,
Y�^'b�. Lye ly 1Q•sft. I'c ft t3/c.L/9,,,, yf'cta:i.
Facility/Owner Name Facility lD#'(ifapplicable) ft ft
2 aS Mow 9 eq n� 91 v c(— tO b"j eJ,(,,s 6,„I k c_ . ft ft ,
Physical Address,City,and Zip ft ft. ` . 1/�_. i
3 :W=iLRF IAMMc;.'fi e"".x:�= _ k4' . _Wit:_ ,E t`b' ' ''a 4'=F:3'>ie
..ercdcl� •
Y6yt-c5 Esc _ � .2023
County Parcel Identification No.(PIN)
Itlf:rtv.airr err..._.,:_ .
5b.Latitude and longitude in degrees/mirintes/seconds or decimal degrees: - •-•••�..,;� i.;t;
(if well field,one lat/long is sufficient) 22.Certification: D Q.fir. o
`35,6l9 0S N Yo,gisgc . w us.,s k- Z 20
6.Is(are)the well(s) ,Permanent or l Temporary 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: }i Yes or DNo with I5A,NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cor etruction 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 farm.
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: i 6,5— (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 2@100) construction to the following:
I i
10.Static water level below top of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,IRaleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Injection 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: I' construction to the following: I; .
(i.e.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 27699-1636
13a.Yield(gpm) 1 Method of test:hf '('5"(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:L1 r4 r+v144- Amount: Ti C completion•of well construction to the county health department of the county
• 'where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016