GW1--00254_Well Construction - GW1_20240105

1.Well Contractor Information: • •
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Garrett Clause 14 cFSri ER:40NES:;cF::V:: R1 b a: -r:5=7A1 Wii::1.;r;4„c-r.. '.f l<:.`w:z
FROM TO DESCRIPTION
Well Contractor Norm •, ft. It ft.
4550-A ft ft
NC Well Contractor CertificationNumber lgt plt 00IN,GMor,:mvl'f r�sed;•vgellsj 0•,t?I;SNEgt(ifcx�""Icar'le) `4.EvM r •
Morgan Well&Pump, INC FROM TO DIAMETER aUCRNESS MATERIAL
k#1' ft. • ft. 0 y$ in' S Vilit\ PVC_
Co an Name BSI l O U)i C< eothem`%aI cTos'ed lob =; ST C+sna _mix:=J3:t
mP Y / ;:00.1IER C- lt11.', PI
{�l ���� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): .r-..•_ r
i[ie:S:CR R4-'1.� fAVP A`..:' X'alit-A*% s �Y..•,__,; "•n .
Water Supply Well: FROM TO DIAMETER SLOT sine, TRIMNESS , MATERIAL _
DAgicultural •Municipal/Public ft. ft in
El Geothermal(Heating/Cooling Supply) ►; 'esidential Water Supply(single) ft, ft in.
Industrial/Commercial DResidential Water Supply(shared) BsiG74t010m'.� q.....0. . ie " :" .t* e E _ • '3'
Irrigation FROM TO MATERIAL EMPLACEMENT NIIETHOD&AMOUNT
Non-Water Supply Well: . 6 ..ft. rip rt. f1e,,h,„i,,-e___ pc,-f e
Monitoring EtRecovery ft. ft'
Injection Well: ft ft
NJAquifer Recharge n Groundwater Remediation t, 7 a t te r - s
K1:4' ANIi7..MV:i,L'ist-Vtil?applicatIgi;.'.444N - saf t
*Aquifer Storage and Recovery . ©lSalinityBarripr FROM TO MATERIAL EMPLACEMENT METHOD
gukquifer Test InStormwaterDrainage ft ft
1)Experimental Technology al Subsidence Control ft. ft.
•
•Geotherraal(Closed Loop) DTracer
L0 12>I U Q-g14thl =aadifi'e'iri.Vi-03S.c_essaty)i` z..i`s' ` �;'aCM
FROM TO DES CRIPTI N(milt-,hardness,soillmcktype,grain size,etc.)
Geothermal(Heating/CoolinngRetum)1�fl Other(explain under#21 Remarks) O ft. S ft �"
t d. 1 'U `1 Well ID# S it C ft h.)(‘-'Al)-(P .
4.Date WeII(s)Comple e •
Q f
•
5.ft Y6Sft. t. 1V.C. IS � r_5 (,,,,.�
5/a Well Location:
J r d _
( _0U-I t LacA..QI ft ft 7 ���w
�+ ft ft. '.4L r L r F�E C.J
Facility/Owner+N ee . FaciityID#(if applicable) t �)
1(l 1. V"' \�Vr •ryew q lcs(L. C1N:A> (1,. ft. ft. A.N , 2024
Physical Address,City,and Zip ft i Ih,..TrI.,',Z
County `1 Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/rniriutes/seconds or decimal degrees: —
(i all Jed,one lat/lo el sufficient) so, S—Ct I „/ W 22.Certification: . O, , -
S• S/t_JI(� b/ N (�� W ��-- P e cen'6 r. Z r zd t5
• Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)MPermament or 0Temporary •
By signing this form,I hereby certify,that the waifs)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or No • with 15ANCAC 02C.0100 or 15A NCAC(DC.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 of this form. 23.Site diagram or additional well details:
S.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 if necessary.
' drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.5/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3@200'p c12 00') construction to the following:
10.Static water level below top of casing: ((�/ 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
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11.Borehole diameter: P (in-) 24b.For Injection 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: r 7 construction to the following: •
(i.e.auger,rotary,cable;direct push,etc.) 111
. Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY' LS ONLY: f • 1636 Mail Service Center,Raleigh,NC 27699-1636
l ' Method oftest: "(( ?ro'ts`J�- 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(pm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:ar el n"l Cr'.(' Amount: completion.of well construction to the county health department of the county
where constructed. •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016