GW1--00250_Well Construction - GW1_20240105

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1.Well Contractor Information: • ' •
• aGarrett Clause 4 lZPEM =a5iT`~ ;ZE- - >r A`!k.` .:
FROM TO DESCRIPTION
Well ConttactorName 51 Q ft. 1 V 1 ft.
4550-A ft ft.
NC Well Contactor Certification Number
15EDARM-(9AXW rMift d: e71'sj-'O ,Id R('-'.'.".ri.i3 e) ' ki g t , .
Morgan Well&Pump, INC a. ft. ft. hDIAMET}Ex THI Ess xrn•TERIAL
CompanyName " l Vb 1 ri'b". •. tieiMiatiR. tatk;.G 'themie(°eLose�7.'-Ibopj` ix'r��r.`d3:rL...?F c�fit EIffit
FROM TO DIAMETER THICItNESS MATERIAL
2.Well Construction Permit#: ft ft in
List all applicable well comiructton permits(i.e.VIC,County,State,Variance,etc.)
ft. ft in.
3.Well Ilse(check well use): .� ._ ,. a �4. .:�t;.0...tiu y
till:S.l FFN i A A.W. •:zh':.:3=4:t tat.'S±eIIs..t'-x •..nfr7 .,i.v:.i: •S:Li:.
Water Supply Well: FROM To DIAMETER SLOT Siva _THICExESS , MATERIAL
DAgricultural Municipal/Public ft ft in.
_j Geothermal(Heating/Cooling Supply) PliResidential Water Supply(single) ft. ft in.
Industriai/Commerciai (Residential Water Supply(shared) {o]$ G D'-OT. sz= 3a3XM'x _; x .•1=i n g r u WMn r._ _ 1 tr,
� � FROM TO MATERIAL 1 EMPLACEMENT THOD&AMOIINT
gati
V
Non-Water Supply Well: • .ft �P f. "' t.4--�__. )V 1,.,f e3
Monitoring DJ Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge D Groundwater Remediation % A"C�r ?aPPlicatifejN7 :w..,= r3, ~'y 3='mot-
3Aquifer Storage and Recovery _3Aquif �� Salinity$arrhgs FROM TOft. MATERTA7• a EMYLACFNIEIITMETHOD
•
er Test QI Stormwater Drainage
Experimental Technology IDSubsidence Control ft, ft {
,0 1bgr tf0X -"(atf3ic a dfi lrillegt3fthecea 16 r:fe t zi O �4V.
Geothermal(Closed Loop) DTracer FROM TO �TION(c Ior,hardness,soil/rocktppe,grain size,eta.)
Geothermal(ileating/CpolingRcturn) [ I Other(explain under#21 Remarks) /� `(aJ(Jl t r\.'
i V) f' A
4.Date Well(s)Completed: 1�`t'�3 Well ID#
5a.We.11Location: ft coc ft ibex vOZV
e, ft* ��ft* N2\031/4 CI( �
Facility/Owner llama ,`Facility (if applicable) c\Y ft' cb `rJ
Physical Address,City,and lap
4V0 n / V. `(� 7;-. - s ' =e-\.: is S c �►1�-•.-'e�,•.4« ss �
/\by \ \ ;�i1 ENL TF .c- _ 3 3Tbx :ass . R
County Parcel Identification No.(PIN) 1 E D
5b.Latitude and longitude in degrees/mbiutes/seconds or decimal degrees: .14( V.7 ,1GZ¢
(if well field,one lat/longisssufficient) / 22.Certification: - /�
1C, 516 N �'0, 3 11/,1� W '":�rr» :i, -3 �_ C `I rcl.)
•
• Signature of Certified Well Contractor Date }`�
• 6.Is(are)the well(s)(d''ermanent or �ITemporary - -
By signing this form,I hereby certify that the welts)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cl se�Ti--Loop geothermal Wells having the same You may use the back of this pike to provide additional well site details or well
construction,only 1 GYT 1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also#ttach additional pages if necessary.
• drilled: SDBMTTTAL IN51'RIlCTIONS
9.Total well depth below land surface: �� - (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q20L p'r2Q100r) construction to the following:
ID.Static water level below top of casing: (f) Division of Water Resources,Information Processing Unit,
if water level is above caring,use'+, 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: j,,On-) •
24b.For Infection Wells: In addition to sending the form to the address in 24a
• s . 'above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: lb° construction to the following:
(ie.auger,rotary,cable;direct push,eta.)
Division of Water Resources,Underground Injection Control Program,
FOR WA:1'1cR STIPPLY, FELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: 2_l.k•(c•— 24c.For Water SnpPIY&Injection Wells: In addition to sending the form to
• /A N the addresses) above, also subniit one copy of this form within 30 days of
/� I' b�. completion.of well constructi.on to the county health department of the county
13b.Disinfection type:L'1N a n aC Amount — where constructed. •
t
Form OW-.1
North Carolina Department of Bnvironmental Quality-Division of Water Resources Revised 2-22-2016