GW1--07171_Well Construction - GW1_20231101

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• WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information:
Garrett Clause %;14 TERZONES•`M•'..:f.—Z-:g.' 5 `"'.t ; '.,= "r=r": -3.`e�.:a fo,5,. o4 ..4
FROM TO DESCRIPTION
Well Contractor Name .. l ft 12• ft
4550-A J
ft ft
NC Well Contractor Certification Number f 15'OSiniR=C SING(far f case"dgyyell-s):Qx2yINElti(it '•)rehire)`; ,-1 `; ;; •
Morgan Well &Pump, INC FROM TO ft 7in.
ft S DILIA PVC
C
• Company Name /, 2✓ (+7 �7,GII,YI`IEI2GA$IlY� R'"�Ol'TtBI�iC��otlie>�geIosed�Itiop1 i��'.,si..��s:=�:M
H ':.";�
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2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL
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: =11 S:GREEDI`X-i `3r.y.' ':l-altai•=.fi u=`Y_r"_t z F :' vE• .
FROM TO 3 DIAMETER SLOT SI,t. THICKNESS Y MATERIAL
DI Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) ',AI Residential Water Supply(single) ft ft in.
I I Industrial/Commercial DResidential Water Supply(shared) - _ - _ A
i'z�StiGRO��r�'•,i.�'�Ts'�'t�1_s_``.!"'�x^}:��<•"'�:WFLL�:c`r.3�-.,�=-i:��":_f;�?s.`cif�i +v=.
rIi Irrigation • FROM TO MATERIAL EMPLACEMENT I¢ETHOD&AMOUNT
�
Non-Water Supply Well: • 6 ..ft. lie ft ,},,,„i,)-e__^ 'QOv cej
Monitoring DIRecovery ft ft
Injection Well: ft. ft •
tiAquifer Recharge riGroundwater Remediation
:,-''19`F,ANtetaki : .tE ACI (I UPplic'a`ble)i•4ii— °'r u.l"'!.,r.'S:`.•1�-,.'`i.;�t%Y
• *Aquifer Storage and Recovery ©I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
11 Aquifer Test D Stormwater Drainage ft. ft.
I Experimental Technology I0Subsidence Control ft. ft •
MI Geothermal(Closed Loop) ®(Tracer AZO'diRil -IN'GX.OGi(atlae`Ir•�addifioz%al;s'heets t✓i rek.'ssary) 'ifl i=s -;;;fir%>4:!.W-i
:i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rocktype grain size,etc.)
/ Q �ft. �ft. n�J ti��,
4.Date Well(s)Completed: /0-3--�� Well ID# .?ft !!!1-�JJ�caa ft (zee,
�A � •
5a.Well Location: ft I C S ft. fie/ e r c^.
/f, _M,' 4- Home) ft ft `�
!(�G!�[t o!I b . , _ arm,-_
Facililittyyy/(OJwtnerName b Facshtty�ID#j(if applicable)
• ft ft �RIt��1I, 1� r l'jy" J
3 o Pc-Pr ulcoc) e 60.`t�i ft. ft ' No it) 1 2020i
Physical• sifal Address,/ City,and Zip L (f��Q r 4 f ft
6 4 vd 1 _ V1 O J -/SS ` .;?/kal iMARKS' .i;:x1c;...iAo. •.,.s 't,R-i'•. ,12,J:,M•¢3 ."'w`r `;r =57? >>
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
. Sr.I 1965 N 8I- I 1<-6q W t -- C Ai Z3 &Z3
6.Is(are)the well(s) ermanent or DTemporary 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: ILDYes or No with 15A NCAC 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 form.
23.Site diagram or additional well details:
S.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: 1' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f 657" (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@2002@100) construction to the following:
10.Static water level below top of casing: L (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.) •
24b.For Injection Wells: In addition to'sending the form to the address in 24a
__ T,/ • above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'fit 17 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: p • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! 2 Method of test:,e4if •5 ��` -lc 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C •'qi fl"(NC Amount: C 6Z completion•of well construction to the coi my health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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