GW1--02857_Well Construction - GW1_20240510

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1.Well Contractor Information:
Garrett Clause -• 'PTION
FROM TO DESCRIPTION
Well Contractor Name ((`'i p ft. 32\ ft• ` I
4550-A LivJ it. ir)( f. L I
CefificationNumber ,G formv'le e'd eIls7 OZ21VITL-`IERIC MkczY ej"; 'a,`�,tr f3's;:
NC Well Contractor 's�.'�1`�'y-©Y��r:0�� j(
Morgan Well&Pump, INC • FROM To MAMEI A& 1xiCENESS NATERTAT
ki- ft cL\ ft a y$ in. sivvu\ vvc,
CompanyName 0 ��?v, .. ,.`ti
�G jG �Yb;'-IlYk`�C-�S1�Y $'Ifi�BI�TC:�othetv`i =dosed'luopj5=,-•s,=�a��;.=. .-ct2.���i`
4/ / FROM TO DIAMETER TRICI{NESS NATERTAr,
2.Well Construction Permit#: `/ ft. f. in. '
List all applicable well constructionperlliits(i.e.fffIIIIIIC,County,State,Variance,etc.)
ft ft in.
3.W llUse check well use): CRET bI %tom f'fir: a_�s_ Y yw :;t 'e ( tali S: l'= l% 1 •ie ri :1s- ga;t•A Feu,.- .
Water Supply Well: • FROM TO DIAMETER SLOT Sma. TSICSNESS MATERIAL ,
i Agdcultoral DMunicipal/Public ft ft. ' in.
Al •
Geothermal(Heating/Cooling Supply) residential Water Supply(single) . ft, ft, in. ,
*Industrial/Commercial ©IResidential Water Supply(shale d) orr f - r i, ^ _e '1.V. .=x" r r . . t
• I1loigahOn _FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
® -ft lie ft. +"--' LI-C �U (1-. � e
Non-Water Supply Well: rt-
I Monitoring DRecovery ft ft.
Injection Well: ft . ft
NiAquifer Recharge Ell Groundwater Remediatlon Si l iscome,E,'t1' C rtPP �E ''�*--`^+c`:c v�"'y"^��-`���`-s'
�. l?IZ:' a lica`ble �-I� .,.:t�.. �3'aa:.aut.,�Ls�:,- a,.�.r•�
i•gaffer Storage and Recovery . 0SalinityBathpr FROM TO MATERIAL EMPLACEMENT=ROA
••..•er Test
DStormwaterDrainage ft ft. •
Experimental Technology 13 Subsidence Control ft. ft
(iQeothermal(Closed Loop) ®ITracer O atfa ESCRIPTION"eis ecessary�xru;
FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
ii Geothermal(Beating/Cooling Return) Other(explain under#21 Remarks) Oft f. ,) V:or
�+� /' L ft ..1 . ft tj tow,\ '..�/
4.Date Well(s)Completed# G 1 Well ID# -
)s ft ft. cetnci
5a.Well Location: -1 Ott oft klv ft cock.
Gct s r•� r!O�� � s V ft � ft. �{ UL/ C'a�,�.' r�
Facility/Owner Name FaciuityID#(ifapplicable) 9 5
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• Physical Address,City,and Zip /�i ( .: _-4 _
/�•• O ,rues,.. -x-��:= -!:� z��rf� ���
County ParcelldentificationNo.(PIN)
MAY ?n�4 ••
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ellfield,one latilong is sufficient) •22:Certification: " -• `
• •Signature of Certified Well Contactor Date (iJ
• 6.Is(are)the well(s)fig ermanent or OTemporary - ,
• By signing this form,I hereby certtfy that the well(h)was(were)constructed in accordance
7.Is this a repair to an existing well: 10 Yes or No • with 15A NCAC 02C.0100 or I5ANCAC 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.
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repair under#21 remark section or an the back of this farm. 23.Site diagram or additional well details:
8.For Geoprolie/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 details. You mayalsoattachaddiiionalpagesifnecessary.-
mostraction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells {
drilled: SUBMITTAL INSTRUCTIONS
9.Totalweil depth below land surface:
loktO. (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rdifferent(e=anple-3@200'aid 2 100) construction to the following:
10.Static water Ievel below top of casing: /0 (ft-) Division of Water Resources,Information Pro cessing Unit, .
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: e(I-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this foml within 30 days of completion D.L.well
12.Well construction method: construction to the following. •
(i.e.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: jj ' 1636 Mail Service Center,.Raleigh,NC 27699-1636
' Method oftest: 1'•f C ?(-' ' 24c.For Water Suuoly&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this foam within 30 days of
13b.Disinfection type:af ci n"I NI- Amount: M completion.of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department oflnvironmental Quality-Division of Water Resources Revised 2-22-2016
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