GW1--07633_Well Construction - GW1_20231204

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
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Garrett Clause a9.+'yw1 ?i.: ' i: 1; %A74 . �-ggiy F'- iF-t•
FROM TO DESCRIPTION I i
Well Contractor Name I Cc, ft. `(A, ft
4550-A ft ft
NC Well Contactor Certification Number Atg.br klRC2SINGj(for'ull,i'ace"'d Weigr.C.1;2t 71 (if nPr•,kcable)`, ti ti ! it : '
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
el' ft. •�4 ft a `ig in. s pvtA P V C
CompanyName �A()��s ��Sy gb ^.'G:I3,Y tiC •sn.`1G'ofil(ilt••Cz ��� :u .tTR-•••
-L (�eotlierms`'lc"lose�'-eV �;E`�s�z- M•t
2.Well Construction Permit#:IIII .1 L---IV FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VJIC,County,State,Variance,etc.)
ft ft m
ft ft in.
3.Well Use(check well use): y
f:`1� 5CREELir� � �:4:��� y"fi�'� ��e�'_;'��1�-'�:• ;'��•Y.iA:4� .
Water Supply Well: FROM TO DIAMETER SLOT Gr>F THICKNESS MATERIAL
I Agricultural DJ Municipal/Public ft ft in-
_i Geothermal(Heating/Cooling Supply) ElIResidential Water Supply(single) ft ft in.
LiIndustrial/CommercialDIResidential Water Supply(shared) 'ssokatorro•:i-. ,.-t yr-- � s' "• - g; - ' "�X'-` 4' ` `.�;,
I Irrigation - FROM TO� �y MATERIAL '- EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: • O ..ft r(dp ft. ,` 4-C_ VV"ce
Monitoring EllRecovery ft. ft.
Injection Well: ft ft.
E)'q er Recharge 0 Groundwater Remecliation ti 5AD%GX AL faPlicitEtTOaw rc bVT W; VRit . :r
©I Aquifer Storage and Recovery ©11SalinityBarri#r FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DIStor mwater Drainage ft ft.
nExperimental Technology 0Subsidence Control ft. ft
0Geothermal(Closed Loop) EI1Tracer A O tiI2LZEII% O (atiac�3i adiiifion'slaheets ecrasary��,r sb '4 : uiq
FROM TO` DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
11 Geothermal(Heating/Cooling Return) rill (explain under#21 Remarks) O ft r \ fy
4.Date Well(s)Completed: 1-1m1'' Well ID# ft �D ft. 1 u(jt�W/1J 1°1
,
5a.Well Location:
p to, ft 6 •
S- ft. lei W R
A314 fi.(k (SO()&4 tstn C 5 ft \8 5 ft 10-c] 5,tea' s i6ti aL .
Facility/Owner Name Facility ID#(if applicable) ft• ft
litt7 L _ _ 1 ,� 1 w9� • ft. ft •
• Physical Address,City,and Zip CifjJ �J
Atlit3l n,. 41 �G(IV% .< s- A A y _ tlir .�. ,�. ,.7z 5T4z„ ,
�F: %'°`'i?�: r'.'1:�3_�.fi• ]{a .:�r�s41r-m.rz_ .--..�t-.ai6��:
r .
County Parcel Identification No.(PIN) 1: 0 1111
3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwAlid,onelat/longis cleat) 22.Certification: tr: .n!-.7:c•z�':-i,:2,IJE'A
�
6680 N 1, I•CIV / J W G\.`. ;: L�ibe.0 11,6 s W
• 6.Is(are)the well(s) 1 ermanent or ©ITemporary _ 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: DYes or No 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.
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• drilled: V•••• Q SUBMITTAIINSTRUCTIONS
9.Total well depth below land surface: +r (ft) 24a.For All Wells: Submit this form-within 30 days of completion of well
For multiple wells list all depths i'different(example-3@20Q' id 2@100) construction to the following:
10.Static water Ievel 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.Borehole diameter: (n-) 24b.For Infection Wells: In addition Ito 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: r Y construction to the following: 1 i •
(i.e.auger,rotary,cable;direct push,etc.) /
• Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/.5. ' Method of test:..'f C ?Calk`(_— 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
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13b.Disinfection type: r' 11"(eNC Amount: 7O j completion.of well construction to the county health department of the county
where constructed. I 1 •
Form GW-1 North Carolina Department ofBnvironmental Quality-Division of Water Resources ' , Revised 2-22-2016
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