GW1--00258_Well Construction - GW1_20240105

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• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
Garrett Clause ,4" s, = =:= ; 5w- o., :,_, : ,..: . . . ._.
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Well Contractor Name • N�Q ft k ft. DESCRIPTION
4550-A 1 `CCC
ft ft
NC Well Contractor Certification Number .., �. -y
15 017 Siigna NG;(for' idroi ediTyti s)OIZ1ITI�E$ frnp)ieable)�"aM11: •
Morgan Well &Pump, INC FROM DIAMETER THICKNESS MATERIAL
L� C� )6' ft . g ft. g y$ in. SDoti PVC
Company Name Q 1 J/ �;y ;. _ ---_ ' `
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2.Well Construction Permit#: PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): ft.
ft.
ill.
Water Supply Well: I1Z S:C)3EEN��..�A `��'."--'_4•v<<s,=�r3,<?,s:;<:.t�ti�.;s.��:.-�-�'- ���.r�=' ::_�".1?�:�+�'• -
% F i�
�, FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural Municipal/Public ft ft. in.
•Geothermal(Heating/Cooling Supply) ''fli Residential Water Supply(single) ft ft in.
*Industrial/Commercial DResidential Water Supply(shared) ro ...,�,_.•".-1=f z a-- -'- ° - - =r1 ;r",
I1Irrigation FROM TO MATERIAL _'EMPLACEMENT TROD&AMOUNT
,
Non-Water Supply Well: . 0 _ft ft. ,46 ,,!-;� c),t"L3
IMonitoring Recovery ft ft i
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
'79'=SAlIDY,Q2'�:Y:EC'tP>E1:Cg`(i:aPPlirsble) ?..=-.n':: 'r�"'°.�,1?�"���a';��=: �-;:=�Wr_�ti
Aquifer Storage and Recovery ©ISalinityBarrigr FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QI Stormwater Drainage ft tt-
ft
Experimental Technology I Subsidence Control ft. ft.
Geothermal(Closed Loop) �I Tracer t,00it>ffi�fc X9-0- attach10_: fional s7teeta iieceasa k1 1:5 -•'"-- t omT
FROM TO DES ON(color,hardness,soil/rocktype, dh{ete)`, +
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Q ft ft. ^, h ek- :.,r !''^tom.
a 1n D.
4.Date Well(s)Completed:It Well ID# ft ) ft' /(0trn ‘)_°f JI N v (1-12' /;14
5a.Well Location: • L`�' ft b lbL.e c rroc,r,fi ; V
J ysft col ft -�. ..-
Facility/Owner NamesFacility lD#(if applicable) S ft �C>e)f' &VV
C n( p/ '
l l� JI( (�S Cl'C �i ft ft. _.
Physi Address,City,and Zip �/ __ GGFF
Ct 87 ;2S F—lYfAlxs_ r '~l'. {r:.k.'::r' .>s:i . M 2.c .z:-.•'nO;=r:A-AW
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifl :600eld,one Zng s Y sufficient)N o_ 4.9 l I 22.Certification:
��' /UI•vf'"Jd 3r, 2023
•6.Is(are)the well(s) ermanent or ®li Temporary Signature of Certified Well Contractor Date
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 rE(No with 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
brats 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:
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 details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CCD (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf dffferent(example-3@200'anndd\2(4100') construction to the following:
. 10.Static water level below top of casing: i(C) (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
•
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 11-0'CL'\s Y above,also submit one copy of this form within 30 days of completion of well
construction to the following: •
(ie.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WALLS ONLY: 1 ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1) ' Method of test:At '{p rem`'fc-- 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:Cr gi la u1 aC' 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