GW1--06355_Well Construction - GW1_20230927

tl
•
r r Pflf TEP:1h71
• WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
• t 1
Garrett Clause ;14 i Iz:oxs.s: ;n-wiMm _i , -<r,:.<:c`:h 4�_�r. ;.�.
Well Contractor Name FROM T ( ~DESCRIPTIpONi
• 1 t-tt5f ,L 116'. p
4550-A ft /`-1 ft.
NC Well Contractor CertificationNumber rt-Z-' .- - - _ ;r.
-15r�©U�lItCASFNG,(formultLca4ed's�Pells)%O�'TIN�R(ifnp licable)'.�•.',w�`„.�y'=`�`:"�%''
Morgan Well &Pump, INC FRO1Y1
f. {j 1 ft a'/g tin, Spat\ ?c,
Company Name t-6 17i�T C-�ce1S'I`Gi016117AIN, (etith`e'ffiWati dgoo "4�,. iL g_"_' -_
CAN GAT �:__ :ATE. -r =.,. .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERrALr h
List all applicable well construction permits(i.e.TJIC,County,State,Variance,etc.) ft ft in.
• 3.Well Use(check well use): �yyr eft ft in.
_" .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS�` MATERIAL
•Agricultural DMunicipalPublic ft. ft in. '
I Geothermal(Heating/Cooling Supply) [l_4't esidential Water Supply(single) ft. ft in.
*Industrial/Commercial Residential Water Supply(shared) * _ =tu t;_-_ __ _w.+;t<f V =ry4 :,a;.r';.=
At GRObT- ,: ' `".1:-7 cam'. •. .; . •,... ,.
i (Irrigation FROM TO MATERIAL EMPLACEMENT' TROD&AMOUNT"�
Non-Water Supply Well: . • 6 ..ft elp ft fiervi-0/14-c__ pQv(`e)
Monitoring EtRecovery ft ft.
Injection Well: ft ft.
*Aquifer RechargeDGroundwater Remediation " 9 A KIGRA M d A0:0 faPPliclileji?^ _..u=+w:��_' __a ill21y«= ga
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
NI Aquifer Test ©IStormwaterDrainage ft ft.
•Experimental Technology 0Subsidence Control ft ft.
*Geothermal(Closed Loop) )Tracer $.:20 1iTiniTaNGZOG=(attachadiifio'nal'abeefslaieg iialiV` ,VAMP:'.j !'
FROM TO DESCRIPTION.color,hardness,soillrock type,grain size,etc.)
,_.1 Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks) ft. (® ft \ r r
U
4.Date Well(s)Completed:9 It-'0 Well m# ;),ft j.'- ft ^
5a.Well Location: i S ft ��t�ft ,u i CJ(G„t k_
-Sex f\. .5,';4.. `�7`,lv,�% T OC ft • 1j) u,2. y rcA t-c-
Facilitty/�OJwnerName 1 Fa:7ityID#(ifapplicable) I (i�"r` ? j ft. ��''� °`�rW`tt
6 i VS 0 41 l tJ 664.�a en-) ft. ft J
' Phy ical Address,City,and Zip ft ft r""+!—'-^� tr i' r ,
D.•_ a t rt.�..i�;
r /n(J� ;: I REM9T „,,_,.,,�....--._„ __:„, .•s;::r!„F . -•s _ ::: =s
,„.
County Parcel Identification No.(pn S E P 2 7 2023
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: ,;
(if well field,o e lat/long is sufficient) ififO,rf:v.?..1 f t _-...,+„ g Ufa
�' L 22.Certification: CONC.?!C.
W q,
6.Is(are)the well(s) ermanent or 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: DYes or No with 154 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additiopal 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
ZDC�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'an 2@I00') .construction to the following:
G 0 . I
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"+" 1617 Mail Service Center,4Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
{_ _ T r above, also submit one copy of this firm within 30 days of completion of well
12.Well construction method: '11° C�� 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: // ry ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpmIO Method of test•.14I { ( I - 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 et n"(6.0 Amount: \\6 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