GW1--07852_Well Construction - GW1_20231205

• WELL CONSTRUCTION RECORD (GW-I For Internal Use Only: I
1.WellContractorInformation: •
• Garrett Clause „„ �' .. �:.. ' -T"` -._;_•�'
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M T DESCRIPTION 1
Well Contractor Name • {1 IU ft �ft.
4550-A •
1 ft 111 ft I
NC Well Contractor CertitcationNumber """" """" ... - '""-e ")'b - ,«- }..
�1•�%©I72'k112_C�ENGi(fPT..mn'lt:rav �."..e71s i'S?,.�T;INEgt(ifr'nppkcaY�"•b`,le)5:;:��`-x�'��':%1:.• •
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERLIL
CompanyName 1 V•S Cl�J 4 'w -� •.
a I (v �X6`:IlYI`��C��Ii,YG:OI;�7fiffBIlY,C=:�Oa.'therm`a'I;c"Iused_'-1tiop�.�,�,:�;C�S",.�'�H�=G:ri�•r33�.'
2.Well Construction Permit# FROM TO DIAMETER 'THICKNESS MATRDL L
List ail applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft in.
ft ft. . in.
3.Well Use(check well use):
��1$TSCREDI1 Y�^ 'ti?w %sa`ti 1 riYnz '_+ � df�&.E Tv'w` S `<;i' s�:i
Wafer Supply Well: FROM TO DIAMETER SLOT sum TRIMNESS MATERIAL _
AgriculturalDMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) f{ ft in.
LiIndustria]/Commercia) ©IResidential Water Supply(shared) Eigokt OT a w,i}n`-a '•K' _ 'z>.,=,:_ ..�>= �'--- r,; .t.
Isigation FROM _ To MATEBIALI EMPLACEMENT TROD&AMOmlT r .
Non-Water Supply Well: ' 6 ..ft ft. , ,t,4-C_ VU u(o)
Monitoring Recovery• ft ft.
Injection Well: ft. ft.
I Aquifer Recharge 0 Groundwater Remediation ._ N: �
`��'.1�` %Q2�,�:ELTM:Ej1.G`K`i£a lica'Eil`e t�+=`_ _. ''�"es v
'S.�D C P - 7-. M��.�:�'a3ti,..��.-'';�n'+''Z���-;.�_
Aquifer Storage and Recovery ©ISalinityBamrigr FROM TO MATERIAL EMPLACEMENT METHOD
•
Aquifer Test Di Stormwater Drainage ft ft. •
q
Experimental•Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracera,2{0 DRTGLIl�IG Oq(attaY`5c,acl3 fifinal s`heeti:if hec`esary�e,;.r y-i rs;Y }?4/4-
FROM TO DESCRIPTION(color,hardness,soil/rock typ e,gam size,etc.)
•
Geothermal(Heating/Cooling Return) n,Other(explain under#21 Remarks)
0 ft. S ft � b;•
iL
4.Date Well(s)Completed:f i—2i-23 Well ID# 5 ft �0() ft Ti io GSA 7•111
5 WWellLocatioon:: 1/� ft '� ft 6 cy "cikAi k,
dell i-44CrA,� �'0D ft lqS ft (,;t, t, 9'444, P
Facility/O are FacilityID#1(if applicable) ft ft. '� 9��, e-.
I/S5 goui-k (� IcJ S‹It,Jf)U� ft. ft DEC ,0 5 2023
• Physr ddress,City,and Zip �l
fv�� �� I 1 i21t N1AT2ISSi i�::x 1:. :-F;:`:, 'E is.Y'� "`*�Y a: f Y' ��,�. T::' l.iR}
County Parcel IdentificationNo.(PM) ' CYBOG
5b.Latitude and longitude in degrees/ ••ntes/seconds or decimal degrees: •
(if well field_o is sufficient) � 22.Certification:
1SI v� yoQ '1 N W /U6deAy,e/ 26. ZE52
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• 6.Is(are)the well(s) ermanent or �I Temp orary 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 No with 15A NCAC 02C.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 ofthis record has been provided to the well owner.
repair under 421 remarks section or on the bacic 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 defeils. You may also attach additional pages if necessary.-
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• drilled 5 Ul3MT1 iAL INSTRUCTIONS
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9.Total well depth below land surface: /V.._5"
(ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells list all depths#-ch:f}erent(example-3@200'and 2 00') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"-t-" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.BorehoIe diameter: (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 metho d: ( construction to the following: •
(Le.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE/LILS ONLY: 1 • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' L) ' Method oftesf:.�{Yf ?MA'S"r-- 24c.For Water Supply&Injection Wells: In addition to sending the form to
�* ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:&,r4A A e.0 Amount: U 6'7 completion•of well construction to the co i tp health department of the county
where ponstructed. •
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
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