GW1--02901_Well Construction - GW1_20240510

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1.Well ConfractorInform?tion: • - ` . I t
Garrett Clause * tW z <<
FR`O�`M TO DESCRIPTION
Well Contractor Name LI�J it. [,tU\ ft I
4550-A - £t ft
15%�O E'.' .IL7G,(for"",3TiK4 e$•We11s7itV3 a-::�gi(iRFP:c2ble)a-,`�:. "x--F.- �.'%. -
NC Well Contractor CertificationNumber ,
FROM }TO DIAMETER TRIMNESS MATERIAL
Morgan Well &Pump, INC ft, 11Z� ft Yg in. SPVJt\ ?V fi,
Company Name i ,S t=Yh,1:6-.$If`TG"O12Zfi II41AC'. othetmaI s`ed3-os _ e d7• :-.:r_
9�J(,IL"' . (V 1—b L MOM TO s
2.Well Construction Permit#: V V ft ft in
List all applicable well can t-lie:onpernits(i.e.VIC,County,State,Varna' sae,etc)
ft ft m•
3.Well Use(check well use): Ylflil,'-:SG`R >.. y. 4 h. ��.,_,.:gin
Water Supply Well: FROM TO DIAMETER SLOT SITU _ TRIMNESS MATERIAL
Agncultmzral 0Municipal/Public • ft ft in
s''�'esidential
'Geothermal(HeatinglCooling Supply) [fig -. Water Supply(single) ft, ft �'
Residential Water Supply(shared) T-r :-.r ire .' -�rr ym . ` ""`c ram=•
LIIndustrial/Commercial ' 1J
PP Y ..,"s-„1"S�U'�O`07r�:�. .�:=,:___r.�-:-..;:s.�'==r=.� _
FROM TO MATERIAL EMPLACEMENT OD&AMOUNT •
Irrigation - 6 .rt it. N46ti Lk- VUU(o
6Ton-Water Supply Well: � + "
Monitoring 0Recovery ft• ft
Injection Well: £t ft
*Aquifer Recharge Groundwater Remediat10a 5X157,G WH Cit: 7 "• -A T 4 1-1z.Ya`
C JL a licalil'e 7 i"• tr2iu i a
*Aquifer Storage and Recovery , DSalinityBarripr FROM TO MATERIAL EMPLACEM NTMETROD
l StormwaterDrainage ft ft
Aquifer Test
;*.111 •
Experimental Technology ©ISubsidence Control ft. ft V
O cane`areiTiaktil reeEces r�') : ` Arif? P IP-'(
*Geothermal(Closed Loop) �II Tiaoer (
FROM TO DESCRIPTION(caIor,hardness,soillmekippe,grain size,etc.)
Geothermal(Heating/CpolingRetum) �]1J Other(explainunder#21Remarks) r\ ft. ft p1) �,CV •
-41%4/elA �� �.)ft /1,6 ft %prow.. ,(f • .
4.Date Well(s)Completed. WellID# 1 1(�)
5a.
�1 ft �L� �r�l.i \'��/
j k.6c-ell Lo cation: H k.lf C ft, ft %.y�eC C 4 1,l) ft feV.0 ft \`(J\�/ I (G-n,\
Facility/0`wn�UerName EacililyID#(ifapplicable) 111 )
• it. £t
8�1c2 t--lc.(iC( err'- (_, `'(er ,(l f ft
• Physical Aclatess,City,and Zip r_ _ f_.:'•
"'' - _; T .<=L:��.U�
County Parcel IdentificationNo.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M''Y 1 !� 2024
("liven field,one lat/longis sufficient) 22.Certification
N 16-d0 ' e` I ) (A `
• Signature of Certified Well Contractor Date
• 6.Is(are)the well(s)ia'ermanent or DTemp°tarp -
By signing this form,I hereby pert*that thew ill's)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or r4No • - with 15A NCAC 02C.0100 or 15A 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:
S.For Geoprohe/DPT or Closed Loop CYeothermal Wells having the same Yon 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 Mach additionalpages ifnecessary.
drilled S UBMITTAL INSTRUCTIONS
CI9.Totalwell depth below land surface: (it)(it) Ma. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#'different(example-3@200'an 00') construction to the following:
(ft)1716
Division of Water Resources,Information Processing Unit, •
Ifwater e level water level below tap of casing:61 1617 Mail Service Center,Raleigh,NC 27699-1617 .
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is above casing,use {•,
11.Borehole diameter: 0( .) 24b.For Infection Wells: In addition to sending the form to the address in 24a
• �if 'above, also submit one copy of this form,within 30 days of completion of well
12.Well construction method: construction to the following:
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(ie.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: j ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v ' Method of test:"-4(f ?�'15`'Ir 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:Gra ti°(&.0 Amount completion•of well construction to the county health department of the county
where constructed. I
Fonn OW-.1
North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
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