GW1--00255_Well Construction - GW1_20240105

1.Well Contractor Information:
Garrett Clause CaVivg ggi :^ ' . , =.A . �k K -ems
n FROM Well DESCRIPTION
Well Contractor Name • 'LID ft. U�` ft
4550-A ft ft
NC Well Contactor CertificationNumber 1§r© SjfyG fc..m e`d•vge�.+7 O Y�I1vEri(ifra licible) M-43-: •
Morgan Well&Pump, INC FROM To DIAMETER TH TCKIESS MATERIAL
)C/1- ft. a. ft 0 '/$ m. $ ILL\ PVCCompany Name n 6"aI '1n2"-- OiDI tl'IFBII'iC:Ootlierna' [a..,rS1�ied l'o :` riiisVI, 7g'=� kwr
2.Well Construction Permit#: 3 q Z. V `�2. FROM TO DIAMETER THICKNESS MATERIAL
.List all applicable well constructionpermils(Le.UIC,County,State,Variance,eta)
ft ft in.
ft ft. in
3.Well Use(check well use): •
iiZ.'':SCRF,EDii f*: = .r e&-. :5 FiditP�::�a ;4g—E . i-rM •
Water Supply Well: - FROM To DIAMETER SLOT SECS THICKNESS MATERIAL
DAgricn.tual [MunicipallPublic ft. ft in.
3Geothermal(Heating/Cooling Supply) ZResidential Water Supply(single) ft ft in.
Industrial/Commercial (Residential Water Supply(shared). #:•544At-OVAL 1 i' s-. -E - :::—gF= s Z£='=- 17,—'-
Indgation FROM �TO MATWnTAT. EMPLACEMENT METHOD&AMOUNT
pon Water Supply Well: • 0 ..ft t ft ,4•6„tt,1-e_,. 1? �,U ,
re 3
Monitoring DRecovery ft. ft.
Injection Well: ft ft
*Aquifer Recharge D Groundwater Remediation u�,R; a lisle i. -Nab =3, -,,yn`_,t =
eD g g5'A i ORZ (i PP 'r:.
*iAquiferStorage and Recovery . DSnlinity.Baodgr FROM TO MATERIAL u EMPLACEMENT METHOD
*Aquifer Test QlStormwaterDrainage ft ft.
Experimental Technology
DISubsidence Control ft. ft'
*Geothermal(Closed Loop) DI Tracer i LRVIt1IIGIIN f(X9 (af}sr"Ti.=sRdifi3nal; eats ec`essar;'jVr ,__�.�:t,, :i _
FROM TO DESCRIPTION(clor�hardness,soiUmcktype,grain size,ate.)
• Geothermal(Heating/Cpoling+Rehmm) BJ Other(explain under#21 Remarks) O ft. !a . ft J iCl
4.Date Well(s) /
Completed: l`-0.03 Wen ID# I 0 f (atun lo`��
5a.Well Location: 3a ft ft 5 IJ,,
ft ft 1Ft ct l��poi(-�—
j��w>ul,ic., �. i yin ft.
Facility/Owner Name aacility
ID#(if applicable)
S (T76 IL�A/6i 1 y 6/OK ft ft
f. ft
Physical Address,City,and Zip �_ UL .. ;r.:-
0J�. 2w. a�.231,1 SRTF. t,,T�%x=3��i :-r E:=>`-'':,`.T,.r y�,six-: .vU x`:
County Parcel Identification No.(PIN) — J�IV C $I !
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a~ 2024
•
(if well field,one lat/long is sufficient) 22.Certification: inrJt•R',g,:izri,'.,...f •
g5 Th' N ( U/ 66 64' • W Q ` t/200 •
• • Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)r! 'ermanent orDTemporary •
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 r*o with 15ANCAC 02C.0100 or 15ANCAC 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 farm. 23.Site diagram or additional well details:
'ox Closes Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
aonstmctiondetails. You mayalsoattachnrhiifionalpagesifnecessary.- •
drilled SU13MITTALINSI'RUCTIONS
9.Total well depth below land surface: 86 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii#erent(example-3@200' 2@100) construction to the following
10.Static water level below top of casing: (f) Division of Water Resources,Information Processing Unit;
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: (m) •
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
M
12.Well construction method: ! VT',f r construction to the following:
•
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYVIS ONLY: {� " 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method oftest:hC 'S ��`-' 24c.For Water Supply&Injection Wells: In addition to sending the form to
//** I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:L'?N"4 n"I 4C Amount: 1 Za Z— completion,of well constmcti,on to the county health department of time,county
where constructed. .
Form QW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016