GW1--07185_Well Construction - GW1_20231101

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: .
Garrett Clause a;1$:tiY:t�Mb= QiOS WE4 w, - . 'g '"ti9..., wi .
FROM TO DESCRIPTION
Well ContraetorName `Ito ft ykl ft
4550-A
ft. " ft
NC Well Contractor CertificationNumber - ;. _r tie rameig�-; ._.. ,,;,,... ,,z<.
xl�„-©I1177R_L�9$IN,Gy(fqr.;mn'lticaseflryells)tOkt?T;INERI(ffrxp`lieq, e)�.s:'�•�:_�;•,... '
Morgan Well &Pump, INC FROM TO DIAMETER TERCIQwESS MATERIAL
it. Sg ft (� yg in. S P t\ ? V C.
CompanyName Q �} q �O ! _
���-mow o L 3�'QQ0 1 N'6 T11' zaTe2$I1%.012'11:ItEIl_`awith6-5-1 ciose3'-lao-`p):`s .A-17-5: <`'.=:`�'af.er}i
2.Well Construction Permit#: • 1 ' FROM TO DIAMETER THICKNESS MATERIAL
Lut all applicable well construction permits(Le.TIIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in. .
Water Supply Well: `I .S.CRBEbIre.,"' • y?'::'--ri=�;,;f2 .Lri' - ' "=ww t =' i #'t;:r'
FROM TO DIAMETER SLOT slza T ICINESS MATERIAL
X Agricultural )Municipal/Public ft. ft in.
ig Geothermal(Heating/Cooling Supply) ic'IiResidential Water Supply(single) ft ft in.
*Industrial/Commercial ©IResidential Water Supply(shared) $ {`t W4 �4y �r�F;e;r_ w. c�=x- 7: ,
��'ti�GRObT:.. _.r.^t1..�v-a--a?�:�.. =� -..q. „� =?:.�.a.:�4-"- �..:�3:�n�.
' !Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' 6 ..it rip ft. ferv,11:5/01--e_. IRUu co)
Monitoring DRecovery ft ft
Injection Well: ft. ft
EllA uifer Recharge 0Groundwater Remediation
:L19.'$21NDY.C`Ltk1agtE,'ACMrf?:aPPlies`1iYeV•,Vm:li=;:-`iA��.�^§y,,z'�^+i'-S-.k:LsraWaSY
®II Aquifer Storage and Recovery ©ISalinityBarripr FROM TO MATERIAL EMPLACEMENT METHOD
!='YAquifer TestoStormwater Drainage ft ft
DExperimental Technology Ill Subsidence Control ft. ft •
RGeothermal(Closed Loop) DTracer t2o i)Bh lr G OG`(atiap''I�'-sdd fionarsli et3`e.alle ara- 7.' -V s:i-�r'r-_RMit
(Heating/Cooling Retnm FROM TO DESCRIPTION(color,hardness,saillmcktype,grain size,etc.) '
Geothermal(Ii g/ ) Other(explain under#21 Remarks) �ft � '�'11.C'_�\ Y �,
4.Date Well(s)Completed: Well ID# ft 0 ft 4p:^� '
5a.Well Location: • l v it 36 ft V/v N^rot.tn (`{jc�
:74°C n.q( `g rt(j _ 3D `6S ft 3 1"tj g r9 c` .,
Facility/Owner Name Facility ID#(if applicable) ft ft Sr-. b r,-:=.„ ;: r""�
1 u° live HWY �/1 6-6 1,) /-f-ll . ft. ft 7,(�
' Physical Address,City,and Zip NOV O V - L`2 3
�,� z .-..r. . - L% 1W, ..,..
L t�ILdR�'gri��sif<-:=.c9'.'�. ':f- ,V�:�?�.'Y+,'.TMe'C`•�.`.iL\'•..L<:•r•.`.z.�u�-" .':w's-�:bs��
County Parcel Identification No.(PIN) '• :;.
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. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • '
(if well field,
one let/langis sufficient) / 22.Certification: r
g� �16 N Fa. SL/SJCJ W 'Ij� ?C> n a�.,
. 6.Is(are)the well(s) Pernranent or DTemporary/ • Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the weli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mown 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.
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drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di ferent(example-5@200'and 2@1001 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 .
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
11 12.Well construction method: V-„{__ T- ` above,also submit one copy of this form within 30 days of completion of well
'°'[� /7 construction to the following:
(i.e.auger,rotary,cable;direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL j' ELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `1 ' Method of test:h ?ctus`ic_ 24c.For Water Supply&Infection 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:( Rtr4 A"(aC Amount: lb 12 completion•of well construction to the county health department of the county
where constructed. I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016