GW1--07175_Well Construction - GW1_20231101

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• WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only:
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1.Well Contractor Information: •
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Garrett Clause is y. s. Ob Ww . :��-.. - g�.,r,. -u13'.���EIt7A1`IE �:�,. �;-�.-,�-�-�N-._..t � :^�:1€=•:?�:y
Well Contractor Name FROM _TOI DESCRIPTION
1 ft �' ft.
4550-A '
ft ft.
NC Well Contractor Certification Number - w y <Y ,
fail. IIIVOT CINO((fieiMII iedzgells)tt�R,LIl� •Tft ifsli lic I.e) ��. ttf/ : •
Morgan Well &Pump, INC FROM TO DIAMETER ' THICKNESS MATERIAL
CompanyName el. ft. gar ft f� '!g in. SDVL\ ?V�- -
U ,a a6.= i:C t)AS1IY OR. I3Bb.IN lr:uReotlie> e]ose3'-3goP '=- .�g-5a`:'ah:�??,: ,?, :"o '.
2.Well Construction Permit#: _1\ U` SROM TO DIAMETER THICKNESS • MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in. -
' 3.WellUse(checkwelluse): • ft • ft in.
Water Supply Well: fail-SOBEE si X I :-'ira:` EF,-S 3 =gv _ f, 0 A1z 2 '• . .
FROM TO DIAMETER SLOT silk. THICKNESS MATERIAL
3Agricultural DI Municipal/Public ft ft in.
0Geothermal(Heating/Cooling Supply) n��Residential Water Supply(single) ft. ft in.
Industrial/Commercial ©IResidential Water Supply(shared) e , ru �.
;.5'B�GRObT>�'`;v�;.�-.�ul�,; _,��;_-.;>�-'�==-.taY:rY_sr�=c:� =�'�r�=`*.,�a•gl ,";•ff7.,
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
M
Non-Water Supply Well: ' 6 ..ft ft ,ielti i,)-c-^ )c i ce3
DMonitoring Recovery it. ft
Injection Well:
ft ft.
*Aquifer Recharge O Groundwater Remediation
'19'S / e ('1?`(' applica-tiVi7.F: ;._r'r,::J:V?;c: "V t ti`:
x Al`IJ)':OI2A`�T;EL�;A >f: t •;<_-h�� Y,ti•.�.z��.a��Ts.=i:`���`�� s�
*Aquifer Storage and Recovery ©ISalinityBaIrlpt FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test ©IStormwater Drainage ft ft.
Experimental Technology Di Subsidence Control ft. ft. '
..1 Geothermal(Closed Loop) ®ITracer AV:taiRIGMGIOG.`-(atta ad2ifionfiriheetsWiecessarp} r";`r.: 2''• :;i:eMa
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
I Geothermal(Heating/CoolingReturn) Di Other(explain under#21 Remarks) 0 ft /) gI \ , r
\0'k\-.L+� `v ft. Zp ft Se ��.,�� •
4.Date Well(s)Completed: Well ID# �w Wq __
5a.Well Location: C ISf& ft 6 0 ft. �0�, KC�
% \\ / 6o ft zt 1 le,<-j g.y_
70 .o /G,t;
Facility/ram er Name h Facility ID#(if applicable) ft L ft
ft' Physical Address,City,and'Zip ft
( 4Svo N. ';5c1J•1b_Osbb .1 wz,fAl2Km'x Wit; _..0:s :1.•::''15 3' f -,antg ;rx-44 Y.,:z%.4-:t-
County Parcel ldentificationNo.(PIN) i:ti ::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • r)t`x'�_```' -
(if well field,one latllongis sufficient) 22.Certification: •
IS: 20736 N g i, -al S SU ' w ( 20�3
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• 6.Is(are)the well(s) Permanent or DITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerkfy that the weltfs)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or r4No • 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 consintetion 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 GVT-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: ! (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100' construction to the following:
10.Static water level below top of casing: G/v (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 L S- ! - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ` �\ /y construction to the following: •
(ie.auger,rotary,cable;direct push,etc.) I '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: {�// ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test:.Fh(f •( Ctar`re.— 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
13h.Disinfection typ e:C'ti 4inof QC Amount: 77V Z. completion.of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016