GW1--00276_Well Construction - GW1_20240105

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1.Well Contractor Information: .
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Garrett Clause 61.3tAF3 tgrizOWSWIMMV- .:-s'. =s=s-.:-ajWi ` p r44 w>
FROM TO DESCRIPTION
Well Contractor Name L 457
ft. i(-tk ft.
4550-A it ft
NC Well Contractor CertificationNumber t$:E.077;.C]jRK_ .5-IN, (for lrrasB e1fi QV Kltiaila)icWe)a`-', ' x5 •
INCFROM TO DIAMETER THICKNESS MATERIAL
Morgan Well &Pump, I NTft, 61 ft, ( yg in. $tV,t\ ?Vc,
CompanyName L/l
0 ,�'1OII51 ' i.G20NG:012f` 3EM../C:Oauth—raai osi�,iiii kgfire` .j..5a h::7...is
7\ 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / / ft ft in.List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): •�-: -uhru r
�1i$:.�.CBE)+;bi��.,��^% �:�.S��s'�' a,'.,iz ��dy�'s- '-�" r''��.�'t�i: - z.::rti�`
Water Supply Well: • FROM TO DIAMETER SLOT sl'/.N. THICKNESS _MATERIAL
Agricultural DMunicipal/Public ft ft t
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft �.
Induslriai/Commercial (Residential Water Supply(shared) �s:-00 . , . ,k-1 -,, 1 5.4; €i,mac �a =>>`tfi` " '
FROM TO MATERIAL. ENIPLACEMENTI E TROD&AMOUNT
Irrigation 0 .ft. rip ft °l r'n 14'C_- pc)
ce
Non-Water Supply Well: v- U
EllMonitoring Recovery ft. ft.
Injection Well: p ft f.
*Aquifer Recharge D Groundwater Remediation
k1s'•- o-
9'KANBKW`-Er AMEX-` (if'aPPlicable�i •t'T.M1 �a :a45,i'Ma
**Aquifer Storage and Recovery ©ISalinityBarrigr FROM TO MATERIAL EMPLACEMENT METHOD
MiAquifer Test
0StormwaterDrainage ft ft
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n Experimental Technology 0Subsidence Control ft. ft
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*Geothermal(Closed Loop) ®ITracer
',NVIalT7N OCx(atfac'Taali.ti'ailit ibVI-s1eceasar9}-r T.Itz�-�.-` :
FROM TO DESCRIPTION(color,hardness,soiUmektype,grain size,etc.)
Geothermal(lieating/Cpoling Return) n Other(explain under#21 Remarks) Q ft ft. tit) `K-5:
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4.Date Well(s)Completed:11=Z'IS Well DM ft ft...) ft `brov/s (V. '
. •256: ft. ft' 5 1...,,,,„, N(t.►c.1,--
5a Well Location: �� ft E ft. (1`�- Ey
�G SA c�Ck�:nd l� �-// q_r s o
ft ft.
Facility/Owner Name
Facility lD#(if applicable)
- ft. ft
ft. ft
• Ph al Address,City,and Zipcs .H _ `_ x. ,,,.,5 P
` �lizRF,vsalzs� �y=Fi; s==r :. itsa1 {3c .lt ;
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Parcel Identification No.(PIN) 5 -U L i \/�t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J, N . ZUe?`�
(if well field,one lat long is sufficient) 22.Certification: 0 i U
6, 3Z�3a N 'ict,2�132� W t .� Zo23
• • Signature of Certified Well Contractor e^
• 6.Is(are)the well(s)frA''ermanent or DiTemporary -
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 ISA NCAC 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 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 Geoprob e/DPT' aving the same You may use the back of this page to provide additional well site details or well
or Closed-Loop Geothermal Wells h
constmction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additionalpages if necessary.-
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drilled: D0 SUBMITTAL INS'1'KUCTIONS
9.Total well depth below land surface: (-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20�2@100') construction to the following
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use" .-'a
1617 Mail Service Center,Raleigh,NC 27699-1617 -
11.Borehole diameter: 11(n) 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: construction to the following: •
(ie.auger,rotary,cable;directpvsh,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test:.�ly I ?'- ' lam- 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
c;/ (NT Amount gat, completion.of well construction to the county health department of the county
13b.Disinfection type: u
where constructed. -
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016