GW1--07174_Well Construction - GW1_20231101

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Garrett Clause III M>e xzoX ': ti �T. ��=.7 z .
s, s ;����?�:.>-ter=:�=?». : .,
FROM TO DESCRIPTION
Well Contractor Name .• • I1 _r .ft ft
4550-A lx,,
ft. ft !
NC Well Contractor Certification Number n15YGT. 12==C'9SIN.GRfira°' ' e ella)a t(i8sp_cal`le)'" ""'r-`''�•>';,, •
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. ‘g ft yg in. S DILL\ PVC,
CompanyName , tic �,.r. 1. kl .,sr� -
4�6iIi`Ii`TER:C-Ab`.13,YG:OIL�CTIIlYCz geottierm�n�close3'-loop)'.- =8�-s�.-Sr«iir=3?-�=��"
' 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lut all applicable well construction permits(.e.IJIC,County,State,Yariance,etc.) ft ft. m;
3.Well Use(check well nse): ft ft in.
Water Supply Well: TR SGRFE)!T O zlz:.:n AMETE-. SLOT r TaicrtriEss M TERIAL .DIAMETER. CM?
DAgricultural JDMunicipai Public ft. ft. .in.
Geothermal(Heating/Cooling Supply) Dili Residential Water Supply(single) ft ft in.
Ll IndustriaUCommerciai )Residential Water Supply(shared) gz-GotrziS;`w`'?34i ._-`-•`- i' :-:-o 'rr`�'-xtn ?w . `7v
�I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINL
Non-Water Supply Well: ' C) ..ft rip ft. 11-c__ VUu(1L3
Monitoring DRecovery ft ft
Injection Well: ft. ft
NI Aquifer Recharge DGroundwaterRemediation ^µ s r.� -
a.§0 ND'IQ2B'��'.EI+V,AI?l �it??PPlicsbre,6+T..:S"t earl 1 s'61 ';`s`lt•-at s.._ xstiw
*Aquifer Storage and Recovery ©ISalinityBaxnigr FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test ©IStorrwaterDrainage ft ft.
•Experimental Technology IDISubsidence Control ft. ft. '
NI Geothermal(Closed Loop) DTracer azk Os7iRII:IING OG;(a{f.cTi a fion'als ets'Wnecessaryj r i`:ird-s e
• Geothermal(Heating/C,00ling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(colas,hardness,soil/rocktype grain size,etc.)
��jj 0 ft. fo ft b.�r
4.Date Well(s)Completed: rd-S-ZJ Well ID# I ft5.) ft AMUL 114.. '
5a.Well Location: J ft ft. Spyk),5'1r
(lark, Cgs ra-c 1 `J ft 100 ft. Sark-A VIOCL-
1 Facility/Owner Name Facility ID#(if applicable) ft elosf ft 3 f v_/5 g(C f .
goasee ` - ll�+,5'� e4 s,GA: ft. ft.
^^
• Physical Address,City,/annd Zip 2� I 1(� ft. ft.
6"�J�ii.-• cY/ �'Yc 1 /r t'.lI-'tREiyp.d�2 s`t`.�;t%,n._. . .. �'. =`vl•:"�' ,...., ` "F :e3 >.'•,va`,`,-..-
County Parcel Identification No.(PIN) 't '4 NOV;...":"::I';i012t .')5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O J 1 �
(ifwell field,one lat/long is sufficient) / 22.Certification: •
`351 1S'?S N LIo�3o. In.�,7,.�: . ,., if„,
• 6.Is(are)the well(s)_,'ermanent or ©ITemporarp 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 1XNo with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/a:own 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:
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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thrilled: �` 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 di,#erent(ecample-3@200'rgid 2@I00) construction to the following:
10.Static water level below top of casing: G (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: (in) •
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
S Y •above, also submit one copy of this form'within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Undergroun• d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1J ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) YC) ' Method offest: (( ?calk.r-- 24c.For Water Supply&Injection Welll: 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'1r'4i n(.1 ae Amount: i 6 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