GW1--02902_Well Construction - GW1_20240510

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1.Well Contractor Information: ` • I r `
Garrett Clause 45Y ©1? 's. j DESCRIPTION
Well Contractor Neme .. - ft TO/SC -
4550-A ft ft I ,;.
Igeg ,- IN;G(Ar•.itii�"ig li e11's i 2?' E ifi _lic' Y'le) 4 a:
NC Well Contractor CertificationNumber �•' �...� � f�� �� )�
Morgan Well &Pump, INC FROM To DIAMEDKR TRIMNESS MATERIAL
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•, ft 10 3 ft Yg in. 1 S PU-A ?V C,
CompanyName 6^ C 4tithe f=�':tnj:'_e •x1=" :
Vl�' e -ZI/0)ol -0 TR
FROM TO DIAMETER xg(CI4+E55 MATERIAL,
Z.Well Construction Pernlmt#: J ft ft ill. ,
List all applicable well constructionpermits(i.e.UIC,County,State,Variance,eta)
ft ft in.
3.Well Use(cite ck well use): y7.s R�l y s``� s � ' F" Y V, c i�1°kv: ,
Wafer Supply Well: • FROM TO DIAMETER. SLOT sv� _ TSICI ss MAMMAL
LI Agdcultoral DMunicipa'UPublic ft ft in.
1 Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft ft to W.•_ _��.
dvstrial/Commercial QIResidential Water Supply(shared) st•_ p`.IITz:;�„7.— 57.0 r•,y:.•me* :�-; z` *�� •° ram'
FROM • �TO MATERIAL EMPLACCF IDhENTl TROD&AMOUNT
Irrigation. ® -ft lJd ft e jro-k_ 1) f'etJ\
Non Water Supply Well:
i onitoring
Recovery ft ft.
Injection Well: ft. ft.
Xi•. 'erRecharge 0GroundWaterRemediatien tr alt3T. My fr PP yr `�yt ` `�g`'lk'
a &ca'bl'e�k7�l,{,r• F ��W. 1.-.,�Yr-� 4
*Aquifer Storage and Recovery . DSalinityBan7pr FROM TO MATERIAL EMPLACEKI NTMETHOD
Xi•golfer Test DIStoImWaterDrainage
ft ft. •
Expeumental Technology 11Subsidence Control ft. ft. =
ails, iaftr nai`alrgs ecess2111Tr i:24-z-``-= 8ali.
Geothermal(Closed. ®ITracer0 � (
FA O
( FROM x0 DESCRD'TfON(color,Laziness.soil/mcktype,p�ain size,eEc.)
11 Geothermal(Heating/Cooling Retina) J Other(explain under#21 Remarks) 0 ft f} ft I'7 e, 1 V c\--
4-Date Well(s)Completed: 14�8-VI Weh1ID# `Lv ft 7-' ft V cave, \)`•e-h
. ar.). ft `rL,5 ft. l cvDe= rZ�c
5a Well Lo cation: -1 �� �G {�9� '
M14u, Loh (/ r(�� L5 0 Pl /g e� �c /ten
G� �i /`! FaefityID#(if applicable)
ft ft
Fac>7ity/OwnerName -
2.61/1 13uJ A(„J-)- At) /144den. • t. it.
ft
PhysicalAddress,City,and Zip 1 ^F=. t,-c E::T�=�1" ' "aN Y%��?v r
�65�1(5777q.0 Tt a _ ,xz,:a: ._=__. _= -
County Parcel TdentifieationNo .,,.—FT 77,.4„,•t.,.i .v 1,-;:tt_,9'
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Sb.Latitude and longitude in degrees/m'oiutes/seconds or decimal degrees: MAY 2024 •
(ifwellfield,onelat/longis sufficient) 22.Certification' .
56.2a q2 N Yl. 1(2 S W , - 4:. es l es) z c( .
• Signature of Certified Well Contractor L'i L't:3'LK� Data
• 6.Is(are)the well(s)rx.'ermanent or oTemporary - '
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 r4No with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Con'siruction Standards and that a
Ifthis is a repair,fill out known well construction information and ecplain the nature of the copy of this,record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For geoprobe/APT or Closed Loop geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additionalpages ifnecessamy.
• drilled: S UBMTTTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 (it) 24a.For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'gndr 00') 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"-i-" 1617 Mail Service Center,Raleigh,NC 27699-1617 •
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the foam to the address in 24a
12.Well construction method:
k -0 3mS if -above,also submit one copy of this form within 30 days of completion of well
construction to the following.
(i.e.sage,rotary,cable;diredtpusb •etc.) •
. Division of Water Resources,Underground.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Jf ' 1636 Mail Service Cents;Raleigh,NC 27699].636
' Method oftest:•4Y( ?1'�`'r-- 24c.For Water Suliply&Infection Wells: In addition to sending the form to
13a.Yield(gym) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:aret iA s,C Amount 6 oQ. completion,of well construction to the county health department of the county
where ponstrocted. .
From GW 1
Nortfi Carolina Department of Environment'Quality-Division of Water Resources Revised 2-22 2016