GW1--03949_Well Construction - GW1_20240705

1.Well Contractor Information: - .
Garrett Clause xaxz© s Y- ,I �r--: ':
- FROM �� DESCRIPTION
Well Contractor Mune . 160 ft. ff.
4550-A ft. ft
NC Weil Contractor Certification Number fi1a701 R4800gfpr,:miti case 'wells)' IAISAKiffx�' F0 e) = � k :
Morgan Well &Pump, INC FROM TO • _DIAMETER _ TRIMNESS r ATERIA_L .
el ft !o ft a `l$ in. spa\ ?VC.
CompanyName `
� f C.I4'i£Iii[2iC 0.RU f:B.AICz .thli rmi T.g°,:ose p ,sa'tigfi r,: h%
FROM TO DIAMETER THICKNESS MATERIAL
2.Well nsirucli Permit ft ft in
Lint all appliCocable wellon constraCtian permits a UIQ,County,Stars,Variance,etc)
ft ft in.
e(c eckwellnse):
3.WellIIs h =<G;:S:CE IDOLS-• ' graUfas= ls ..62MV;g ltiMS :w; KT .Ik .
Water Supply Well: • FROM TO DIAMETER SLOT Ritz .THICKNESS MATERIAL.
DI Agricultural Municipal/Public ft. ft. in.
ElGeothermal(Heating/Cooling Supply) SISZtesidential Water Supply(single) ft, it in.
U Industdal/Commercial DResidential Water Supply(shared) mU](tox7T p a: = - ?` ri A = 1 * _ ~=
�I hligatiOA FROM � {
TO MATERIAL, EMPLACEMENT OD&AMOTUNT
1;on-Water Supply Well: • • 6 - ll'J it +"' elltWI s U"�
Monitoring la[Recovery ft ft �''
Injection Well: ft ft t L ` 1
Aquifer Recharge Groundwater Remediation r i,� ( aPPli le r7•c s� -�i +
Aquifer Storage and Recovery �SahinityBammigr FROM TO MATERL L EMYLAOEMI C�[ET 11�
Aquifer Test ©J IStormwater Drainageft ft �1/1 [L(UJ
I SnbsideuceControl infern"..ta Cr3 ,,,,.''6n¢• 7.2
J Experimental Technology JIB it, ft jpril .
Geothemmal(ClosedLoop) Traceria 01i9 (altacT{ fionalsheetstiecessary�x: o-cv _
FROM TO DESCRIPTION(color harkens,soillrecktype,grain size,etc) '
Geothermal(Heating/Cooling Realm) Other(explain under#21 Remarks) ft Zfr., ft 1
(� U
ri-
4.Date Well(s)Completed:���� Y Well ID# �f�� z� � t-
5a.WellLocation: ,��' pp "v.7,) � � j jIr 0et,
Tom
ou&( ,,
Facility/OlianaerName FacilityID#(if applicable)
i1L/ iftvt¶ 44-(f '.) % ft ft
ft ft
Physictta
Address,City,and Zip '
1 la �11'�ItEht_ l c:a:,,:-x "'.? 9 t. tea'-`-...
County
�� Parcel TrirntificafionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
' (�fwell field,one lat/longis sufficient) �®I����� - W 22.Certification:
• 6.Is(are)the well(s)rA''ermanent or y Temporary Signature of Certified Well Contractor Date
By signing this foray I hereby certify that the wel()was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No - with 15d 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additiolal well details:
B.For Geoprobe/DPT or Ciosid-Loop Geothermal 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. Bulicate TOTAL NUMBER of wells
construction details. You may also?mirth additional pages ifnecessary.- •
drilled: S uBlVIITrAL INSTRUCTIONS •
9.Totalwell depth below land surface: - ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3@200'and 2@J0') construction to the following:
10.Static water level below top of casing: VO (It) Division of Water Resources,Information Processing Unit;
Ifwater level is above casing,use"+" 16171V1ai Service Center,Raleigh,NC 27699-1617 -
11.Borehole diameter: j,,(m) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i-y construction to the following: •
(ie.auger,rotary,cable,-direct push,eta) t
• Division of Water Resources,Underground Injection Control Program,
FOR WAXER.SUPPLY WELLS ONLY: 1 ' 1636 Mail Service Center,Raleigh,NC 27699-1636
_ 13a.Yield(ma) ti ' Method of test:hr ?��`fc— 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:G' rei i'l"I a( Amount 2 cn,„ 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