GW1--02184_Well Construction - GW1_20240408

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1.Well Contractor Information:
• Garrett Clause `sue a—'-- c• -Lt: 'FrW'` a: '-:'n4Z?:C-`z,;:zx*= :
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FROM TO DEscnre ION
Well ContraetarName • --at) ft.
ft.
4550-A ft. ft. I ,
NC Well Conimctor CertificationNumber 15%r;0U itare4 N,G,(fprm"In it;-a g3+,�°�`e71s7�0?f.: .$tf PPacab�e) rt y 1:1•: •
Morgan Well&Pump, INC DIAMETER T IaI SS MATERIAL
FRO ft ft. a ` t in.
S .m;\ v_vc
CompanyName ./ J LS ''-0000 V l oil •6 3 IXaC- ,S7x Okat 1ttaltigr TH[ ' a 4:, �:c*• L'
eothel�? closed'[eoPZg �a��r«=ot'�".�.�
FROM TO DIAMETER CS:NESS MATERIAL
2.Well Construction Permit*: ft. in
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc)
ft ft in.
3.Well Use(check well use): ti sc� .;a,r'• v
i�li't�•S.Cw,I�IFra:�ew3"�-.i�'�;.s'y'� �'�•"��;u]=�•.A�'r�s�" Tom,. .:�x =.ziti>-:� .
Water Supply Well: FROM TO DIAMETER SLOT THIGKNFSS�cc MATERIAL
Agricvltural r3Municipal/Public ft ft �-
Geothermal(Heating/Cooling Supply) , .Residential Water Supply(single) ft. ft i•
Industriai/Commercial QResidentialWaterSupply(shazed) ;r1g�GT€ooT,;�=_-v--'4iti-=t'. '`:�:-`t?=•*= yam`-----"' `` '=?. :j-'-.y° •2,
Irrigation FROM TO MATERIAL 32,2PLACEMENT TROD&AMOIINT
Non-Water Supply Well: • ® ..ft. ft. fei -' C-- '�U"�.
flaiMonitoring raltecovery it. ft.
Injection Well: ft. ft.
*Aquifer Recharge DGroundwater Remediation fig;may e` te;g ia']icalile7t tMi ;: ih1 a `
*Aquifer Storage and Recovery . 0SalinityBanigs FROM TO 1VIATERTAL EMPLACEMENT METHOD
•
••.6'er Test
©1StormwaterDrainage ft ft.
•
•Experimental Technology 0Subsidence Control ft. ft.
•Geothermal(Closed Loop) ®(Tracer
0`D12Il v .Mafird,,Witionalshee£srf4ecessary) a :.:M.. `•,� 'l4 l
FROM TO DES TION(color,hardness,soillmolttype,grain size,etc.)
ii Geothermal(Heating/Cooling Return) �J I Other(explain under#21 Remarks) 7 ft •17 h 1ot,`i
4.Date Well(s)Completed: Well ID# ' -
ft _Y ft IV ccc ^ Val-l- .
5a.Well Location: 3'C� ft -t�o ft G�1 -9r cv'
TOS/�p{� (c 2ei,ft' ,oJt •(/.'Nrlf, r'J t'c,.1It-e
Facility/OwnerName F jilityID#(ifapplicabIn) •`'.— vr,? r • „,Li,
6663 P(0tr�i; ( .1LeYCo V2J Via", ft. ft.
ANR �7` ZGZ4
physq�ss,l1LJ��1.31,//and Zip 7. 7 //�66 _ _ ,
[/�•/1{" �C7/.��L v/`„� sal].�RT.1l�Al21s:`i�s`1'v' '-=^s s'f,':r't.� '::}n;';ims� �s.: _'•`�:'n` •, x: -
County Parcel IdentificationNo.(PM) ^`"i J n L1 C.
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well
l�field,one laatt//longissufficient) �S �f 22.Certification: -
J/ /29 N lCSyZ�/ W •44 ,iav N. ?Z3 .
• • Signature of Certified Well Contractor Date
• 6.Is(are)the well(s),'ermanent or OTemporary - '
By signing this form,I hereby tern),that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or 6No • with ISANCAC 02C.0100 or 15ANCAC 02C:0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and ezplain the nature ofthe
copy ofthis record has been provided to the well owner.
repair under#121 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 if necessary.
• drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer 6 (ft) 24a.For All Wells: Submit this form.within 30 days of completion of well
For multiple wells list all depths ifdrfjerent(example-3(Q200'and 2@100' construction to the following:
10.Static water level below top of casing: b ( ) Division of Water Resources,Information Processing Unit:; .
Ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617 .
11.Borehole diameter: (n-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
i'if •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 WELLS ONLY: 11 �7 . 1636.Mail Service Center,Raleigh,NC 27699-1636
3 ' Method of test: 'f( •[ I i -' 24c.For Water Supply&Injection'Well : In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
�c'7- completion.of well construction to the county health department of the county
13b.Disinfectiontppe:r�'�tl a�+�l�C Amount: • P -
where constructed. !
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . 1 ; Revised 2-22-2016
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