GW1--07626_Well Construction - GW1_20231204

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• WELL CONSTRUCTION RECORD (GW-'11 For Internal Use Only:
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1.Well Contractor Information:
Garrett Clause gi'4ev4 . f z z s g - = , .-�t . ,: k -F
FROM TO DESCRIPTION I 1
Well Contractor Name .. 1,60 ft 1 ft. I I
4550-A ft ft j
NC Well Contractor CertificationNumber 'gl$:t`O iO' ILIGj(fgrin"iilWerSiil e11.i sQR?I:IL ERtiftu)cable`,�„ a="`=x'"_�,r *=
Morgan Well&Pump, INC FROM TO DLAMETER 1 THICENESS MATERIAL
)6- ft. IL ft a ` g m. S Dtt\ �_ PVC,
CompawName 6;p4NDR"C-�Ei.ST G:OR :B21!to', otiieo q"1os'e31'-pbpji,`vH:> :ziug-a.:k,1c•`
2.Well Construction Permit# CNA-W .,-2o2,%-6014)
: FROM TO DIAMETER 1 TffiCIQZE.Ss MATERIAL
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List all applicable well consiruclionpermits(i.a VIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well.use): ft ft �!"
t1g.S.(�-B�'+I ti ^'3.M-."-.moo;,-'-'s-'-a`.' �"`5+.''M`_� .cla .�3v' '^Z::'�`'.Ccc t^ ..:•:.` :i-
Water Supply Well: }jt -
pP Y FROM TO DIAMETER SLOTSI%.N. THIC%I4ESS MATERIAL
Agricultural 0j MunicipallPublic ft ft in.
Geothermal(Heating/Cooling Supply) `!y;Residential Water Supply(single) ft ft. in.
LI IndustriailCommercial DIResidential Water Supply(shared) _� ;.;� ,; c— t,�-, ; = s=_
R1$ G$OO� e• 'v. 1?.r _ S �µ, ii =yt Vr5 #r�3izbY
Irrigation FROM TO MATERIAL EMPLACEMENT TROD&AMOTNT
Non-Water Supply Well: ' 6 ..ft. ft ,t,I '�U Li re
Monitoring nalecovery ft ft.
Injection Well: •
ft it
11 eRechargeL-1'Groundwater Remediatioa __o _ ..r_ ,.hh. ,_
Aquifer ti.R.T lGLtA;•. A'L�£PACl (if:apptintiilgOaie`''.';:: A»3i�a::'tS'aiti- iti.-
AiAQuifer Storage and Recovery . ©ISalinityBarrigr FROM TO MATERIAL EMPLACEMENT METHOD(
liAquifer Test 0 Stormwater Drainage ft. ft.
rig Experimental Technology DSubsidence Control ft. ft. '
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MI Geothermal(Closed Loop) ®ITracer O.DR1»G (Q'(att8c'h.�addifiTn"sl;sh ets ec`.easary) �-; ?;I:=`€..y `,
Geothermal(Heating/Cooling Return) BI Other(explain under#21 Remarks) FROM TO DES CR TION(coior,hardness,saitlraek1.grain size,etc.) _,
4.Date Well(s)Completed: t 1-I 11'23 Well ID# W ft ft f� ` 'b 6 A/
. Na ft ) ft. GALj, J� C 2023
5a.Well Location:
tic( S c J '�(� ft ft bef r c` " _r
(JCf,L� e 0;AR_, If:iC;1C?_:r.�Il 4•s,?. liIti••
Facility/Owner Name Facility ID#(if applicable) (a? ft ft. Pi i) 1 ('4..t
68$ C)to) .S41,sb�r ()Deco() Ni) • a° ft. �20 ft o h�k/QIic., g, k,
• Physic a3,14ddress,City,and Zip C ��
C1&LL ;nSM.1�2TFC" s'�Sew...- r_r?-.+�1.",�:3`-^'•�::.`.�r..�'n:�r�.5 ~:�1ur�w.t'e��'`�w'=x`
a. ( =
County ParcelldentificationNo.(PIN) .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) p� �j 22.Certification:
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w 776� N Off.-' 7 .tz /U Ve,iJV W 7.,43
•• 6.Is(are)the well(s) Permanent or DIITemporary Signahue 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: DYes or JXNo with 15A NCAC 020.0100 or 15ANCAC 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 ofthisform. 23.Site diagram or additional well details
8.For Geoprobe/DPT or s d-Lod Geothermal Wells having 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 ifnecessary.
• drilled: SUBMITTALINSTRUCTIONS I
9.Total well depth below land surface: �� (D-) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdi Brent(example-3@200'and Z(�100) construction to the following: I
10.Static water level below top of casing: (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.BorehoIe diameter: Cm) 24b.For Injection Wells: In addition toj 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: �Y construction to the following: ' •
(i.e.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: / - 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test:•-'i(C 'f{�("0-35`Ic 24c.For Water Supply&Injection Wells' In addition to sending the form to
�lj the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type:aril ii � Amount: 3•� �2 completion•of well construction to the millIty health department of the county
where constructed.
Form Gw-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources 1 Revised 2-22-2016
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