GW1--06454_Well Construction - GW1_20231002

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only. ' '
• 1.Well Contractor Information:
Garrett Clause gseNavalZQNE$; a image%-mz477ssa F-.m-:; ggi x '' < &
FROM TO DESCRIPTION I
Well Contractor Name .• • I/ ft �� ft
4550-A !(� ft. ft. l ' .
s; ia (forran'1ti a galrve11's)"_QRi7 Ttyi.:R(if�sp"plicnhle)' yytz.
NC Well Contractor CefificationNumber �1$:�0�-Y'aNG THICKNESSMATERIAL
Morgan Well &Pump, INC ft M l j Z ft DIAMETER in. sDtt\ ?VC..
Company Name ^ <'C-ASIIYb Cr"OMDFS.NC=O(� `'f='. "ry.'':,
c.'`j S /"i�j/6 ;sl$'�I1V1�ER. r eotlietviaZ;cl"osed�oop`)": �.b�:.=:?�'��-a.�-�s l•;
/V^t J !/ FROM TO DIAMETER THICKNESS e"•MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)
ft ft in.
• 3.Well Use(check well use): ..,.- '`< �: s' m r_:';="_ `
• `YE SCREEN. ._�::S-. i`w 42. ,41, SMI: _`ii
Water Supply Well: FROM TO� DIAMETER SLOT SIZE THICKNESS+ I MATERIAL
i Agricultural )Municipal/Public ft. ft in.
r�Geothermal(Heating/Cooling Supply) ,.`'_>I]iResidential Water Supply(single) {t ft. in.
"'Industrial/Commercial DResidential Water Supply(shared) •rsr l' ifi N; , "s1.i ;=ri:e. '`' `--`fgA_
I'Irrigation. FROM TO ft. 13e °I D MATERIAL_t EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ..ft.
ftn - -- VU v re3
:i Monitoring )Recovery ft ft
Injection Well: ft ft.i Groundwater Remedlatmoa
�I Aquifer Recharge - r.. . VII�t1GIC(ft:a"PPli Te)E- v_' 7u c"r: < r
9. xi9?SAlVli%GR.A,.
I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL m LACEMENTMETHOD
U Aquifer Test
�ISto Groundwater
r Rem Drainage ft ft
J Experimental Technology I0Subsidence Control ft. it
i0.0Filis;:D1111;U`IGZOGattac'fi :% :iiR,`.=s'._+.% ''
I Geothermal(Closed Loop) DTracer a %6'o`nei;ON(color,
hardsary)t
DESCRIP ON(color,hardness,soil/rocktgpe,grain size,etc.)
U Geothermal(Heating/Cooling Retttu/m) [Q�I Other(explain under#21 Rrmarkc) M {t . ft e f l�
4.Date Well(s)Completed:9 rZ/Z, Well ID# 5- ft jr ft. 0.34--el, 'O., Y •
P�� t
L/V ft )O e) ft OP 3'� )t C._
5a.Well Location: ' 8 g !fir, ft n•)` � YL� r )�_
C7v"C-'e' GJ`� a S
ID#(
Facilitytfa applicable) ft ft.
Facility/Owner NamepP ) ,
7.�5 Goy iFec(0- 11-3cc)1s ft. ft ,77,1 y^ ? ,r.,
`P ;: 1=eRE1VY9Z2KSr' x•~>
• Ph ical Address,City,and Zip ( s.r':.'_L_ 1 rt::, '}_ s � tse>rs:5
/ Parcel Identification No.(PIN)
ounty Iri..;'i+,.. ^.FI er. . ...,..'.n i rl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l.J'va _ :i\j
(if well
Ffield,one 1st/long is sufficient) 22.Certification: •
j.6."7 l?Z? N gO.35'?8cf W S9411-e0.13 br a I Co�3
Signature of Certified Well Contractor Date
6.Is(are)the well(s)M,Permanent or 0Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: )l Yes or jNo with 1SANCAC 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 forrn. 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon 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: 1. 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 a(�00'and 2@,100) construction to the following:
10.Static water level below top of casing: !7'0 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater Ievel is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
•
11.Borehole diameter: 110 ti(m) 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.e.auger,rotary,cable;direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/1 Method of test: -( rals`'Pe- 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:Lira A"I NC Amount: O r� 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 I Revised 2-22-2016