GW1--03915_Well Construction - GW1_20240705

• WELL COIN '114.UU1.IU1t.K.EAA.11w lurrr'.LL •
1.Well Contractor Information: • •
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Garrett Clause .tear,�Mrs.- �.. ;,- �-s—t:z-,
ax.4 , .' �'� ''.$.-�a. :tawo' =s��' •: ,.°.s,. c,` o�-:;sw.,.a..,<-.2> ;'`W,.
FROM _ TO _DESCRD'TION :.
Well Contractor Name 2 �ft. �\ft.
4550-A L ft ft.
NC Well Contractor Certification Number ;15x'©D011iK ING tfgr cAre'a• 1'sjP_'GX2 .14- liczY'lej t_'--;4W:Oiri•. .
Morgan Well&Pump, INC yFROM TO �` DrAM/FTFR TBTC MATERIAL SS 5
in. svv,IA
Company Name `-/ n� Gg C-$r;7iy(r."OIL'I_,`T other =close3'-lobp W,t-44•�..3,. -�':? ly
2.Well Construction Permit#: !/ /< FROM TO DIAMETER Tfficraorss MATERtIAL�
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc)
ft. f. in.
(i
:--- f. - - --in. - - - -
. 3.Wall Use(ctte,.Yyea,!-.,v,1
Wafer Supply Well:
�r
FROM TO DIAMETER SLOT Mk, TffiCFNESS MATERIAL I Agrlcultoral fMunicipal/Public ft it in.
i Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in
I I Industrial/Commercial DResidential Water Supply(shared) 4.B otIT4§ ' :":1'.�=�= 'i• "-"•:":;a~ .r. --- -13 :=:'.'�.' .:: '
Irrigation FROM TO MATERIAL MYRI ACENIE T OD&AMOUNT
on Water Supply Well: . 6 .ft (LC) ft ,iyjni,!-� 'I V"�
Non-Water
DRecovely ft. ft.
Injection Well: ft ft.
*Aquifer Recharge Df Gmundwater Remediation
0--.;P D OLIS:(r:FiL A`C]i'•'(ra'P llcablgaiSt`u°:i=r 3% 0s yit
*Aquifer Storage and Recovery . ©IJ SalinityBamrs FROM TO MATERIAL EMPLACEMENT METHOD
MI.. -er Test DStormwater Drainage ft' ft.
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Al Experimental Technology I0Subsidence Control ft. ft
*Geothermal(Closed Loop) ®Il Tracer EIUyD T oix(attar.°a aiTiona'taets' erEssaiyj , =-F` `t' -"•t'�;
Other(explainunder#21 Rtnaarlss FROM TO DESCRIPTION color,hardness,soillrocktype,grain size,etc.),
Geothermal(Heatinp/Cpoling Return) ) /S ft. S f. ' T,.r..\-
4.Date Wall(s)Completed:g"4'-Z`% Well ID# ft 2. ft \34'yn t'
ft t
�� L
051,5a.W Location: 3 e ft
Facility/Owner Name FaciitylD#(if applicable) '7 r0 ' W ft. `,/14- I t&'Na 5t q,i ^'e
Physical Address,City,and rap
County Parcel Ide i;sraionNo.(PIN)
JUL 0 5 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield onelat/longiss sufficient) 22.Certification: (f irri-.ii;:1 ?'ram -
kit
5 ?C to N g1.G-ZF736'. w �w___ 1-vre kP Z0?C.L .
• 6.Is(are)the well(s)`11'ermanent or �ITemporary Signature of Certified Well Contractor Data
By signing this form,I hereby certify that the weli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Di Yes or IG<No with 154 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under ii2I remarks section or on the back of this form. 23.Site diagram or additional well details:
Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
B.For Geoprobe/DPT or Closed Loop
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
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drilled: 5 uBMTITAL INSTRUCTIONS
9.Totalwell depthbelow land surf 2U
ace: (R) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths di Brent(ermnple-3@200'and 2@I00' construction to the following.
10.Static water level below top of casing: gC) (ft) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casing use"+" t Ito 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) •
24b.For Infection Wells: In addition to sending the from to the address in 24a
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above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: V•L construction to the following:
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(ie.auger,rotary,cable;direct push,etc.) l
• • Division of Water Resources,Underground Injection Control Program,
FOR WATER S {�UP.Y LY WELLS ONLY: j (< '[ ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(g(goo) )v ' Method oftest:h MO''r _ 24c.For Water&may&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
lib.Disinfection type:L'/�Gtf'Mi n e(ai Amomnt: 17 G 2 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