GW1--07851_Well Construction - GW1_20231205

• WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information: • • •
•
Garrett Clause ait:aVal?EIR.$© L'.S"sr a'.�-`=t'xt,'.-.M.4 ',.tr,,.,$ .`'sw-'.-•`t3., =`f" z,: f„?c ;..
FROM \TQ DESCRIPTION I
Well Contractor Name • 1 N ft. \\
ft.
4550-A 1 ft ft
•
NC Well Contractor Certification Number "" . ...-j_ rt ,.
.-•.�,:-�w•e Ys�V.L
r15,t©172'k1I�_G���INGr(for..mn'lt.caied�ell+):012�R�(ifds licq,.e)_...�_ ..x:try,*=- .
Morgan Well &Pump, INC FROM TO DIAMETER iTRICFtNESS IV/ATER/AL..
/� Vii," ft. ? ft (� '/(t in' S P%t\ P V C,
Company Name ,,V/n-2 16a.IMl C9S1'/Cr"ORI$I1`T�U dtlier sed'-li o7g 5=ni a`^'; :s x`.
2.Well Construction Permit#:S"J( S FROM TO DIAMETER TB/CR:MESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in. ,
ft ft in.
3.Well Use(check well use): „-�
Water Supply Well: • FROM TO DIAMETER SLOT SiLt. THICKNESS MATERIAL
i Agricultural DJ Municipal/Public ft. ft. in.
;1g Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft in.
•IIndustria1/Commercial DResidential Water Supply(shared) 03 GkiObTt F_ 54?ss=' s ' -a.=`--'1 '- --'•�`_ -'°'��•t- '`-"`''
Igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non Water Supply Well: • O .ft ft. i.,]-� '�V�e
Monitoring DRecovery ft ft.
Injection Well: ft ft.
p�,
jiAquifer Recharge C—'1'Groundwater Remediation VA, - r„ 4 1-= u
'1IAquiferStorageandRecovery . ©ISaiinityBarripr FROM TO MATERIAL EMPLACEMENTIEIETHOD
MIAquiferTest I StormwaterDrainage ft ft
•
n Experimental Technology DSubsidence Control ft. ft •
MI Geothermal(Closed Loop) ®11 Tracer A 0O (atta s�=s Tat;ih-al;iheet's3fnec`atsaiy),"•,``.t.,W-tl"$t 2�.,-E;.h�,-...
-
M . •c•r ON(color,hardness,sm7wmektyp e,grain size,etc.)
11 Geothermal(Iieaiing/CoolingRetorn) �IOther(explain under#21 Remarkv) ft. ft a/'�
rl ��3 WelI1D# %) ft t ft t �y-�
4.Date Well(s)Completed: ��
• $ t. \C5ft. lire/ 5 V 6' t
We� ocation:tO, � dqL L G
f ft .
...
Facility ID# applicable)
ft ft ��••�Facility/Owner Name t3 (if
I Gopfr-cr ,rke, '4'r c41sbcr*— - ft.• ft 0 F C i? 5.7023
• Physilai Address,City,and Zip *+
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) Z2.Certification: • -
• 6.Is(are)the well(s) dPermanent or �ITemporary • Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 1XNo • with 15A NCAC D2C.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 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.-
•
drilled 65 1 SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (A•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: I/O (f(ft.) Division of Water Resources,Information Processing Unit;
Ifwater level is above casing,use"+' 1617 Mail Service Center,Rj aleigh,NC 27699-1617 ,
11.Borehole diameter: 11(in-) 24b.For Infection 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: itconstruction to the following: •
(i.e.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WALL S ONLY: / {� . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (�� ' Method of test:.4"(C f '- -Ir- 24c.For Water Supply&Injection Wells: In addition to sending the form to
�* �f the address(es) above, also submit one copy of this form within 30 days of
C.'1N 13b.Disinfection type: "'i i -1'C Amount: 70 2' completion,of well construction to the county health department of the-county
where constructed.
I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016