GW1--06351_Well Construction - GW1_20230927

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• WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information: • •
tl
Garrett Clause ago' a lYEsy iwir ; za,_, : w Vrti�_§j4 .
FROM TO DESCRIPTION I •
Well Contractor Name •• • 1 C ft. � 4 ft j
4550-A / ft / ft k
NC Well Contractor Certification Number - - -'`CMg7G(forhm'lti cased yells)�bRTINgib ifnp licaple)�,. Kam+'TV s=:
,,a15;OIISI�IR_ ,
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. Morgan Well &Pump, INC FROM To DIAMEIERI I THICKNESS MATERIAL
)6, ft 41y ft a yg ita. Sn�,ti\ PVC _.
Company Name /` n ,.\ �1/ ,',,•i-'6'IIiNTERG95INGr`itaV thi NC; otli idEg tt edger T 4043,1C:c,:
/ H,'r-�c.-"C.023—0OV 6o FROM TO DIAMETERI TECIC€SS MATERIAL.
2.Well Construction Permit#: ft ft lin.
List all applicable well construction permits(i.e.VIC.County,State,Variance,etc..)
ft ft 'in•
3.Well Use(check well use): K4 „_,,;. ,_^:
S.CRF.EDT�`�h���:�•".:^*ry:-fi.��::�-G:'_.�F.,t �.,�_��";c: ":'�:. :]!�_:
Water'Supply Well: FROM TO DIAMEr 2' !SLOT SIZE c THIC1C1ESS� MATERIAL
•Agricultural DMunicipal/Public ft ft in. ':
ill Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) -;,I. :t-ems%-_=_v: ; ":' ~= _ -We-- . `. ``,:
r=1B GROt7Tr.�";�:,. . ':�:. ��:��::.. - ;. ,_..=',' .=,�,''.. ��:=:r-_._,:.c.`::-��z
I!Irrigation . FROM �TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: • O ..ft LJ'p ft. 13e",ketit-t,l-f___ pc),..,re
Monitoring 'i✓Recovery ft ft.
Injection Well: ft ft.
CJ Aquifer Recharge D Groundwater Remediation AND .� _ �
M!19-S 7GZlA. Ta applicabre°)` } =r ,a;: - .v. t'ik_i `• tit:
V.EL. �i� =� _= ;s
• ^Aquifer Storage and Recovery y j(Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
I Aquifer Test I lStommwater Drainage ft ft.
J Experimental Technology DSubsidence Control ft. ft
Geothermal s 20:DI2IL'T.Il`IG;1 OG=(atiac`h"adilifional;aheets necea. `i:.• E-:_Mts�-'•t:"':=I
(Closed Loop) Tracer ���� -•--:-�_r....__.... .
O Z.
TO DESCRIPTION(color,hardness,soillmcktype,grain size,etc.)
LI Geothermal(Heating/Cooling Return) FR
Other(explain under#21 Remarks) ft l p, ft
pc.• 4.Date Well(s)Completed:q-2I-Z3 Well ID# fV ft ....TO ft B teo„A___ -
5a.Well Location: '0 ft � ft. Il lvL/5 f{, S r 4n)4-L
ft. ft
-Cr ltf- 1osk-%4
Facility/Owner Name Facility (if applicable) ft ft �,t.
%00 ��rd�, ' �,'�i�. c
ft ft :`'�, �...��� ��A_,..}ems
tita�rdl�s -
' Physical Address,City,and Zip ft. , =
C6q.fr-J :.irxE Aaucg-t=_e,-,f. - •r.. -as,:k_t'q tv_ _n.,% a w a
r.
Parcel Identification No.(PIN) "`'f.'?7 r.^,�'4,74.''?5j 1 r ll
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County 11 ts:��:^:'-.'..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
5.s q‘d/f N to S7`170 w $&I-t#,,i.-v 2 1 701,3
6.Is(are)the wells) ermanent or ©(Temporary 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: DYes or No • with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fll out]mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form. j•
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.
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drilled: SUBMITTAL INSTRUCTIONS
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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'apd 2@I00) construction to the following: ';
10.Static water level below top of casing: (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 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: 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: JJ " 1636 Mail Service Centi r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:.f 4 (VOL't— 24c.For Water Supply&Injection Wells: In addition to sending the form to
pp** the address(es) above, also submit one(copy of this form within 30 days of
13b.Disinfection type:C r A d16.0 Amount: 262 completion-of well construction to the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I ' Revised 2-22-2016
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