GW1--07639_Well Construction - GW1_20231204

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• WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only. . I'
1.Well Contractor Information: '
Garrett Clause gric.:4 S. .�:. , . :5 zgRx =,ate i-- =a
FROM TO DESCRIrriON 1 I
Well Contractor Name •• • 01V 0 6 ft. ` ft, I
4550-A J ft ft
NC Well Contractor CertifcationNumber - .-..•_ry . "" ,,,,,,'_ z x4
-xI5�0U1'k3R=[z%}t4ING(fPr,:m�`"ln tce3e"d;'47eILs)�O'Z?t��1ERY(rfrapPkc2 e);;�.-treeMi:s::
Morgan Well &Pump, INC FROM TO DIAMETER ' TRIMNESS MATERIAL
VI- ft Ct ft. a `/g in„ s lV1t\ P v C,
C2.Well Construction
e �r1 ll�4a•' -a�-s'?
11 "116 TTPR C S13YG012?]ffB1PTCothenu`ial closeri'lpopjg=a s efrr .�'s's•�v3r-_.
2.Well Construction Permit#: lJJ FROM TO DTAMS ER TmCXC SS MATERIAL
List all applicable well construction permits(i.e.r1IC,County,State,Variance,etc) ft ft m"'
3.Well Use(check well use): ft ft. In.Water Supplyy
�7 SCREEI`i. >a ��tjl5�I�a> '�=�.=����`�%w"';�����,��.lu:� •
Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural DMunicipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) . AIResidential Water Supply(single) fi ft in.
LI Industrial/Commercial �IResidentiai Water Supply(shared) 0�Gll2t)bT: "'.T ',(-fir`_ "r� �� -"'=* 3
I Irri atlOIl FROM TO MATERIAL Enieuc MENTi IETHOD&Amorm
Non-Water Supply Well: • 6 ..ft flip
Up ft. ,114.- . 2c ,...1ce
Monitoring DRecovery ft ft.
Injection Well: ft ft
BAquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery QIISalinityBaaigx FROM To MATERIAL EMPLA.CEME rMETHOD
Aquifer Test 0 Stormwater Drainage ft. ft ! .
DJ Experimental Technology 111 Subsidence Control ft. ft. '
0Geothermal(Closed Loop) ®IJ Tracer 7 I RIZ *%.0G"•-'(atiac�tcarT3 fiausl s5ieet3;ifr�eceasary1€';:ll ` --27v *'"� .
nGeothrrmai(Heating/C.00lingReturn) Other(explain under#21 Remarks)
FROM TO, DESCRIPTION(color,hardness,so;l/roektype grain size,eta.).
4.Date Wells)Completed: (I fIS WeU TD# 0 ft .3,-0 ft V ropf\ ,b.r� '
5a.We1lL cation: - �a ft ft. VE�r,,A i VoL&-
� f `
Vt �J�iSon �G-Uts - • �� � to ft �Q��+!/�sfifi �r�•F-L
Facility/Owner Name 11 Facility ID#(if applicable) ft ft
Qqq 'O',n�— Z.ei Oc,frsu k.e___ • ft. ft.
ft' Physical Address,City,and Zip `+ ` - R
U .5 7 yir ,w,.. -r [' .., f;?i r,-,-,a. " '.rr`"i"..s: t�.a••ti:o
!J •i: =�✓"-e7�v.:_ �::u^a e,r-:x.:rr-c,-5�::��c
County Parcel Identification No.(PIN) i �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: U r C. 3 2023 •
(if well field,
nelat/loonggiisssufficient) Q �/�7�/'/ 22.Certification: • •
Ti1 gJti� N O of ` /'"/` 3 W 'J :.;,-^. n it:; t o etas
•• 6.Is(are)the well(s)A,'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 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 ifnecessary.-
•
drilled: I.!!ll S UBMUTAL INSTRUCTIONS •
9.Total well depth below land surface: `'W (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(example-3@200'and 2@100) construction to the following:
10.Static water Ievel below top of casing: gO (ft) Division of Water Resources,Information Pro cessing Unit, ,
Ifwater level is above casing use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617 .
11.Borehole diameter: (ID-) 24b.For Injection Wells: In addition tO sending the form to the address in 24a
T- ! '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,eta.) ,
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: {� " 1636 Mail Service Center,•RaIeigh,NC 27699-1636
13a.Yield(gpm) 61 ' Method of test:AC 4 12 'lc— 24c.For Water Supply&Injection Wells: In addition to sending the form to
��** the address(es) above, also submit onelcdpy of this form within.30 days of
13b.Disinfection type: Thrsi iA NC Amount: / O'Z— completion,of well construction to the !county health department of the county
where ponstructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016