GW1--07186_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only
1.Well Contractor Information: - .
Garrett Clause ti14 w, TER7ANES; ra ,:a '.t`t '"'T 'i a*'`lx =-
Well Contractor Name FROM TO DESCRIPTION
-• It,) l
ft, r ft.
4550-A C77J
ft. ft
NC Well Contractor Certification Number T13 Ojfl'ER.('ASINGt(formulti cased s'gelis ORaNERI(rfrnp`.11cible)2-t=.:£x M=- IV.: •
Morgan Well &Pump, INC FROM E. DIAMETER THICICVFSS MATERIAL
Company Name K]
ft' v ft /� yg in. S yn.\ p V c.
"�-�- �'6sI]VVPTEItC' G:"OItaT[IBIlY.Cif"eotlierma7;c"losedgoop'j'ag;_i,:a7 �F' ..'1ti%^'c=
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL v
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): ft ft in.
.I11.S.CR7.332 1.4.&1 �;•;;�"-- t;a:<;ism'rLAfe-."_s-,-",,[n�'•tr_". _
Water Supply Well: r •. v. i' = :_e-Si
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural )Municipal/Public ft ft in.
X Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
*Industrial/Commercial DResidential Water Supply(shared) �-_ u }B-_ 'r-_ ry::sj, �51.`_z ,;Wr'": , 1- ,. �,;,•:,
fS$�GRObTt'rr-=:ems.,. . ..=��� - .��,�.����v_3';�:::�,.;;,:.
'►�ihrigation FROM TO MATERIAL u MLACENENT METHOD&AMOUNT
Non-Water Supply Well: • 6 ..ft. ft. Oeiviitvi r,.)-c„ Ye u
re 3
Monitoring (Recovery ft. ft.
Injection Well: ft ft
*Aquifer Rechaz a 0GroundwaterRemediation
g 19:SAND%GRAVFL"T�PAG (iraPp`hia'bl'e) ;«;tr r K °r a s rt?z i ? ""t
• ',Aquifer Storage and Recovery DISalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
MI Aquifer Test Di Stormwater Drainage ft. ft.
I Experimental Technology 0Subsidence Control ft. ft '
*Geothermal Geothermal(Closed Loop) ®(Tracer '24 O ilj-RIL:LTRGXOGr(aiiZrh addifion`aI.a'heets ece+sary): -r °'�.`ik- `. 'iit:
FROM TO DSCRIPTION(color,hardness,soiltrocktype,grain size,etc.)
..Geothermal(Heating/Cooling Retuurrn)�f(l l Other(explain under#21 Remarks) Oft /O ft l > ti;rk-
4.Date Well(s)Completed: 10—Cr^`�3 Well ID# /U ft "C) ft rp�J���anx)A.
TO ft LCJ�ft' A .�-
5a.Well Location: ( w 9 - 54-(A%
X0(.0c)C) �/r 1-e S ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft. ;,r g
i: :! 1 .+
•ci c Veyei n - ck e._ A 3'ISr4Jrg— ft ft NOV J 1 292"
• Physical Address,City,and Zip ft ft
l a /.4(rV-S /.:_______—. ..:d1112EMARKSM.Cf::.-._.. ='r- . r-'%-'.(.t f'.ti::fi^ `:fle,r.',,s'r;.v3N:.ics s'-1:% Sr,,�
County Parcel Identification No.(11N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we�d,one ong is sufficient) IC),
��� � 22.Certification N6 W , .L 00/Z4ed. Z 3
•
6.Is(are)the well(s) .'ermanent or inTemporary 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: )Yes or 174No 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:
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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: iZoQ (ft.) 24a. For All Wells: Submit this form',within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 00) construction to the following:
1,0.Static water level below top of casing: (ft.)(ft.) Division of Water Resources,Information Processing Unit, •
Iwater 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
• above,also submit one copy of this form:within 30 days of completion of well
12.Well construction method: IL° i�-`r construction to the following: .
(i.e.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:.''(f ?CM/ 're- 24c.For Water Supply&Injection Wells: In addition to sending the form to
- Q` n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C-►r'a/►"1 4( Amount: (c Y!. 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