GW1--03458_Well Construction - GW1_20240611

• WELL CO.NS'I•RUUt'IU1v tcr,k,Uxcu (UrvY_iZ x.u..
1.Well Contractor Information: - '
Lfl`.4.2.9 Rs7,01IL:60� '' 'au s x •
Garrett Clause yy" '
FROM TO DESCRIPTION
Well Contractor Name fig ft. 1010 ft.
4550-A ft ft
NC Well Contractor CenificationNumber -r$113 :61404 LI:G(`(fpr.171Di case�vgdllMRY;I IE),t.Te liraelee--'-� -: -
Morgan Well &Pump, INC EOM TO DIAMETER THICHI�SS MATERIAL
Xi' ft' 11 ft 0, y$ in. Spa\ P vc
Company Name 0 �� FROM TO DTAMF`6^<•RZ RCQS'I G.OR7fii3$IH.Cz'Keotlie ;r-ose3l'gbp�r.-e` =4a�:-,.vM «:h"sl `-'-:
'PR72 ADiCP2ESS MATERIAL
2.Well Construction Permit#: ft ft in.yj gll.riplicablaIvaconstructionpe_rmits(i.e.UIC,County,State,Variance,eta)
eII=Use chE1[vr1ius ):> - _
- — --y�-�.y-
-- �-�'��f`w �3�"c^,roz _irz3itt � --`- -...
ater Supply Well: FROM TO DIAMETER SLOT SUE TSICENRSS -MATERIAL
L Agicultua 0Municipel/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) `i!1iResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ®IResidential Water Supply(shared) foEa{O`CT g.r =:f'gfo=':L 'r F+ `- ,__
FROM TO nMATERRIAL EMPLA.CEbffiNT METHOD&AMOUNT
;J on Wafe 0 ..ft 1p ft lbn,-t`,0 �U"C(t
�on--Water Supply Well: • Yam'
i Monitoring EI Recovery it it,
Injection Well: ft ft
DAquifer Recharge D Groundwater Remediation ,vs , O gr(irfi ucaiile'jM7.1R;x st t``ar -
DAquiferStorageandRecovery ©iSalinityBanigr FROM To MATERIAL EMPLACEMENfMETHOD
QlStonnwater Drainage ft ft.
QlAgtnfer Test
0Experimental Technology 0Subsidence Control ft. ft -
Tracer 0LO.-01 1:C tlattar`t iii)i'o'uribeets= Fe's.ECC—f1, L
gGeothermal(Closed Loop) FROM TO D ON(color,hardness,soillrncktypq gram sze ete)
Geothermal(Heatingf Cpoling Return) Other(explain under#21 Remarks) 0 ft. 5-, ft. tI '�,r 1 J U N 1 1 a)4
'+�6•Lq WeI1ID# cft gp ft .{,
4.Date Well(s)Completed: IS
1r Er � 'i'`'C A '�r' err
3o ft 6 c it, c()L. Q+� o�,c, ����
5a.We4Location: 65-fL 11 ft ni tJ
fVe/C'f Irt.":�e•
Y ICJ M�Ct C°1 4�
Facility/Owner Name - FactlityID#(if applicable) F
• ft. ft.
g 15 5.4-i re40 I t Id CA:na.. (Grow
ft ft
• Physical Address,City,and Zip �12-xQ �s_
i 4 :.1.0E11R :l .c N.1 t }e...� '. ._..... -— ... kxo.ss.;- _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
3cc'g 3f3 N Slo, 60 3Z3 • W /1/!p y t6 loll
• • Signature of Certified Well Contractor Date •
• 6.Is(are)the well(s)44'•ermanent or DTemporary - '
By signing this form,I hereby certify that the wellfs)was(were)constructed in accordance
7.Is this a repair to an existing welt: DYes or IXNo with ISA NCAC 02C.0100 or 15ANCAC 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 farm. 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/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.-
•
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
' drilled: •+�^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface .5 1 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following.
10.Static water level b elow top of casing:
!� (ft.) Division of Water Resouurces,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) • 24b.For Injection Wells: In addition to sending the form to the address in 24a
• C Y • above, also submit one copy of this form within 30 days of completion of 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: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/ ' Method of test:Ai ?(-0'1s`'� 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
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13b.Disinfection type:Ctirei n u 16` - Amount 17 0 Z, completion-of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016