GW1--07646_Well Construction - GW1_20231204

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Garrett Clause s q - W . -:,mr & 4 w- _g:= .4..
Well Contractor Name t
FROM TO DESCRIPTION I 1
4550-A
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ft ft. i ,
NC Well Contractor Certification Number -r; -r -� = v:r_ -^zt•,. t• ti,.�_, �r,_;,
�15.,.OIJ2'E&:�95 Gz(fur, ln�csse�v�e71"sf�0�71711'EFt•?(ifrsip�li�i'le);�-:•ti-`-,._;�,:_�-:,•.. •
Morgan Well &Pump, INC ,TO Dr°'v R THICENEss MATERIAL
Company Name J" ft. �S D f' (o yg in.! S DMZ.\ p V C-
mP Y 1 G1 1 (5 6<I1. IER;C-i�$Il`TGAIt'IfiffBIP11�geotlierma cIase31'-i op7:� ?�?k j� lni F::. c:.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in.
ft.3.Well Use(check well use): ft rn
Water Supply Well: 5_:::14-;"Ma=eIWPRaSIL-SiinS..— v Na, .__,._.af;=. .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural DMunicipal/Public ft ft in. '
M Geothermal(Heating/Cooling Supply) L: ''esidential Water Supply(single) ft. ft in.
*Industrial/Commercial DResidential Water Supply(shared) -; .. ,
�;SSzGRObT.�;� -.�=t}r_=`-;ti^��-;��' =:r- `r-� r,.'r-''�`:•4:r...��aV.?r
Iilmgation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
Non-Water Supply Well: ' ® ..ft. 1J) ft vi-yjn t1-c__ Pc - co)
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
*Aquifer Recharge i Groundwater Remediatioa
i19'z_S•k'11STD'%GReI;4316".g(if`aPPlica'h10t.i:i:a:Wi. �i TSiff *c;,itii"._d_*iL,. mil
*Aquifer Storage and Recovery DSalinityBarrigs FROM TO MATERIAL EMPLACEMENTMETHOD^� _
"Aquifer Test DIl Stommwater Drainage ft. ft.
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' •Experimental Technology MII Subsidence Control ft. ft '
•iGeothermal(Closed Loop) ®ITracer 3211 111f;L TIG O'tx'''-'(aftacrtadd fianars`fieefs':i aec`e'ssaryjrr-Z F%- /a Via_
Geothermal(Heating/C.00ling Return) Other(explain under#21 Remarks) FROM To D TION(co
V ft b. ft �� �.lor,hardness,oeillreck typ e,grain size,etc.)
/i1 cry
4.Date Well(s)Completed:\\'1- "/ Well ID# !0 ft .T ft R o,t ). r r •
5a.Well Location: r37l_ ft t w ft. 6C�� 5`RN 1L
►'1r/JiU/l t�iryLL C 1 GU ft 1 it �'n �oJ�p Lj trtro tC�
Facility/Owner Name . 1 Facility (if applicable) ft ft.
q/O/� 6--Ct'43o«) y V is b4; O,` . ft. ft.
' Physical Address,City,and Zip nor '
GC.Saeo\` 1 itIZ a1Y11X,S;4'?1•7. .T...- .:::I n.Z__::R-t- fgl"mac`it:1 .-'4 1 A '.'e:
County Parcel Identification No.(PIN) `'zr;.,--_1... fnl' 4
Rt.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D[ ( _"1
(if wellfifielldd,onela/t/llongissufficient) I (fa
22.Ceriification: V - �" .
CJy1 c fJ
• 6.Is(are)the well(s)dPermanent or E1Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certiify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No • with 15A NCAC 02C.0100 or 1SANCAC 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 ofthis 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 Close3-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: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ( 25. (ft) 24a. For All Wells: Submit this form within 30 days of completion of,well
For multiple wells list all depths if different(example-3@20n0'and 2@100) construction to the following:
• 10.Static water level below top of casing: Cic� (ft.) Division of Water Resources,Information Processing Unit,
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If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: OP (in) •
24b.For Infection Wells: In addition for 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: /7 construction to the following: t
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(i.e.auger,rotary,cable;direct push,etc.) '
• • Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: {� • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 66 ' Method of test:.'4(( '[ ��`''(e— 24c.For Water Supply&Injection Wells In addition to sending the form to
/p� �p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:4'1tf"ei n u4 ar Amount: id Z completion•of well construction to the county health department of the county
where constructed.
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016