GW1--03470_Well Construction - GW1_20240611

• WELL 1..1.1.0t0 ltc.0 li l-LVi‘xvuv v,,,..+-- t...... .�A
1.Well Contractor Information: • '
Garrett Clause aFOM "°"
FROM TO DESCRIPTION
Well Contractor Name ft Az(40 ft. \o
4550-A t'ko ft tko\ ft. 1.0
ro_
NC Well Contractor Certification Number -;IS,;OMIRf_GQS.Il`7f (form°ulf.cs5ecl�vge7ls)�OI2SLIIVEItiC li, _']e)° M„x;- '.,- •
Morgan Well &Pump, INC FROM TO DIAN:EC u THICXN SS MATERIAL
)- ft. \CA 10) Yg in.
1 S �.ti\ p
Company Name VG,M C-9$IlY0OR 10.3.Ili.(:rOothemas(gr"1-oseri.t'-•-45... UW-ii.=N'T' ` ],
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in..___List applicable well construction permits(i.e. C County State,Yorimce etc)
TicR�t�ritca[-wee-lse7 -- - °' %>:. .. -sr'_''-i _. - .. -___ -
RIM Water Supply Well: - FROM To DIAMETER SL Srtii ,THICKNESS MATERIAL _
0Agacult ral DNlunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft m.
rigudusirial/Commercia) DResidential Water Supply(shared) 8,4—GRt7`CJT.-,tAmt.era as •'- ?"a#`✓:.',w. c `. ='7=
• FROM TO MATERIAL 1 EMPLACEMENT THOD&AMOUNT
Non-Water
® _it ' ft. 1.1--L-- Vo u(`L3
Supply Well:
i Monitoring Recovery ft ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation Y - � 7 =t ^: a� � z=
• MASZi;R7Ar. EMPLACEMENT METHOD
Aquifer Storage and Recovery L�J SalinityBaudgr °M TO
quifer Test
F-!Sto nadwar Drainage ft ft.
I Subsidence Control ft. ft
J Experimental Technology -
Geothermal(Closed Loop) Tracer
UCODT DMQ-c.--(at}sc"fi_artai iratatill'efitie.. essazY�:3•t�fia4
FROM TO DESCRIPTION(color,hardness,soiifreek J.e,a` .size,etc.
Geothermal(Heating/Cooling Return) �J i Other(explain under#21 Remarks) D ft \ h r j
4.Date Well(s)Completed:$• 1 Y Well ID# �p ft ,a& ft 1_116 i00A A,P;'
• (emu IL qb ft. �Ot,t, 'Nt k JUN 1 1 2024
Sa Welll ocation: /i,� ft. ft •%\J 1 (a(t y fou
�r�' 06/4'v� �'h.� (ZU LLL "W J 1 `, a c, ?.,.tea:,$U+
I FacilityTD#(if applicable) ��,(� ft Alp ft. `�'''(`Ik/ V f c ' --'Dvv- .
Facility/Owner Name ft. ft.
( 7Q 5 iO W el1`n Gw�.- .
ft ft
• Physical Address,City,and Zip ARF•1t1tAils', ;= ' ?r r E-` +`a ' "l` # 'r '" ` '-
County O �'�` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(rf well field,one latllong is sufficient)
1 5 25 N WO. CAt • W l,alL\ •
• • Signature of Certified Well Contractor Da e
• 6.Is(are)the well(s) iJ'ermaneut or DTemporary -
By signing this form,I hereby cernfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis 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:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop geothermal Wells leaving 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: SUBIYQTTAL INSTRUCTIONS •
9.Total well depth below land surface: (1) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200�2@100) construction to the following:
p (ft) Division of Water Resources,Information Processing Unit,
10.Statictr water level i glow top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
•
IfwaterTevel is above casing,use"i'
11.Borehole diameter: „,(m, 24b.For Injection Wells: In addition to sending the form to the address in 24a
gl 1C� r •above,also submit one copy of this form within 30 days of completion of well
S construction to the following: •
12.Well construction method: •
(ie.auger,rotary,cable;direct push,etc.) Division of Water Resources,Underground Injection Control Program,
' 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
FOR WATER SUPPLY WELLS ONLY: )J
�' • Method of Pest:-41f ?�'- ' l - 24c.For Water Supply-&Injection Wells: In addition to sending the form to
13a.Yield(gpm) )r� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�`�K
/ 1 2 completion-of well construction to the county health department of the county
a n_ " ar Amount: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016