GW1--07131_Well Construction - GW1_20231101

• WELL CONSTRUCTION RECORD (GW-1.' For Internal Use Only:
1.Well Contractor Information: .
Garrett Clause fza::g, s. S : : 7., •>::>. =i? , .;
DESCRIPTION r
Well Contractor Name FROM TO
!g a()ft. I// \ft. I
4550-A V� l(+,
ft ft
NC Well Contractor Certification Number -' trca'^,Re '-);
s�15��©17�k3E�_RsA4SINGj(fvrimt>-.cased;�ReIls OA'ttiNEFttriei"ucable)a.�'`�sty-."�'_"--rr': '
Morgan Well &Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL
)6' ft 6 ft a yg 5- sT t\ PVC
Company Name J(n��� n� t1`6-IiY1`7PWC 1lYC•r`OR+793B.Ilg.,-� e'tfierm cYoseagifi lla. �r fal,.o .
2.Well Construction Permit#: f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.TIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: =0I:S.CitFa[::;-�•�.gfk.-:� '�t��r �ar��i4��r_�E�..::c-v"sr..::-�.�.�nz�;�..' .
FROM TO .•DIAMETER SLOT SIZE THICKNESS MATERIAL
t Agricultural )Municipal/Public ft. ft. in.
J.Geothermal(Heating/Cooling Supply) 6Residential Water Supply(single) ft. ft in.
ii Industrial/Commercial DResidential Water Supply(shared) 1S?G 2"o'D•z fi:`F``*•'3uj: =%—"-0--I:ii? s K='f 4 =x:= ;f` "
K '
' IiIrrigation FROM TO ' MATERIAL EMPLACEMENT IyIETHOD&AMOUNT
Non-Water Supply Well: ' (5 •.ft rip ft. ,Ff-pnt VUu(LJ
i Monitoring DRecovery it. ft.
Injection Well: - ft. ft.
*Aquifer Recharge D Groimdwater Remediation ;.,
ri, S XGRA;V:alMA MIl a'1i1'.0•I xti-.:•"' e.
*Aquifer Storage and Recovery ©ISalinityBarripr FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0 Stormwater Drainage ft ft.
•Experimental Technology D Subsidence Control ft. ft. '
*Geothermal(Closed Loop) ®ITracer "AO: R.I1;IaNG OG°(attar'TiYada fional::slieetsaf-pecessaryj: '. ";`Cris` 'l;;t ;eat '4,= .,-,-:
FROM TO D CRI
li Geothermal(Heating/Cooling Return) B Other(explain under#21 Remarks) 5 �, PTLON(color,hardness;soillrocktype grain size etc.) "
7 ft.
4.Date Well(s)Completed:10•Zs'Z7 WellTD# S ft ft 13�. % Trr' •
5a.Well Location: • To ft p 1 ft. 164.
$ hi_, �..
p/1l 1 i6I C- (- Sd ft ere, ft. tl 1F,�se 5 ram: -
Facility/Owner Name Facility ID#(if applicable) z ye, ft gpo ft. U sr n/L j 1►
'1 W
V JV e74 -5 ^ 1"h i p[K,AH,�� • ft.- ft l
' Physical Address,City,and Zip ft. ft
�y 4 :lis.alE fAizKg PsT,,:::.:. r?i_=. }_`t. `,:to.airr—•-va7,_ cy•a,--'cam° s, �:
Coins y'f ` Parcel IdentificationNo.(PIN)
3
NIIV J S 20>73
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwelldel�elatllo is sufficient)11 -7 N Yo, . ) 22.Certification.: „ , .
_:.,..„, 1_4•73'.
• 6.Is(are)the welI(s) ermanent or Temporary • •
Signature of Certified Well Contractor Date
Z�
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 1XNo with 15A NCAC 02C.0100 or 15ANCAC 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: goo (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@2000'and 2@100D construction to the following:
. 10.Static water level below top of casing: o (ft.) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: (in) I
24b.For Injection Wells: In addition to sending the form to the address in.24a
1 _ -! -above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Cz� 17 construction to the following.
(i.e.auger,rotary,cable;direct push,etc.)
• Division of Water Resources,Undergr and Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1J . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: . ( ?( - 'tom-- 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:ar4 A"t ac Amount 1 Z G 2.- completion-of well construction to the county health department of the county
where constructed. •
Fenn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016