GW1--03985_Well Construction - GW1_20240708

1.Well Contractor Information: . I • I
Garrett Clause '�` �'"�''�� �a .: 4 ;
;141Y
FROM TO DESCRIPTION
Well Contractor Name •
Zc, ft. 21,.\ ft.
4550-A ft ft
.
NC Well Contractor CertlfieatiouNrimbeI ist15x0I7 L RQ,Gi(fg eflr�malt c�s `e71s)bR R Ci $c e ""
Morgan Well &Pump, INC FROM TO DIAMETER ECENESs MATERIAL .
)6-* ft. : 10 T
ft 0, `/$ in. S)%' \ PVC,
CompanyName ,�1-.'¢" I g C-AS'INCrOR"';"1__'ItB7P(Q;'( otfiemuaI Yose11'ii ,' t4•�,.R3gf' :: r `
2.Well Construction Permit#: Q I I FROM TO DIAMETER THICKNESS MATERIAL
`� ft ft. in.
List all applicable well construction permits i.e.VIC,County,Skate,Variance,etc.)
ft. ft in.
3.Well Use(check well use): �y J, _� r 4
b#X!`3A�'' .dSh.�BFi.� W- :� n-y.[:._-_.v,YYr'Y:;fj
tSupply Well: FROM TO DIAMETER SLOT SIZE THICKNESS _MATERIAL
'cultural �Mimiripal/Pnblic ft in.
hermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
•
sirial/CommercialDResidential Water Supply(shared) •SzU` ObT. wt.��,�% =`1, f -<-` ` 'Irrigation FROM TO MATERIAL EMPLACEMENT TROD&AMOUNT
I �
Non-Water Supply Well: • 6 ..ft (1 ft fce ,i,l—c, vU U(..e,
Monitoring )I Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge D Groundwater Remediation r
'.SANDYOBTA'V�L ,'AGWiri Plica'lite M•V1^ i -VEM= ii'fttM-,-
Aquifer Storage and Recovery . DI Salinity.Barrigr FROM TO MATERIAL EMPLACEMENT METHOD
uifer Test
DIStormwater Drainage ft
•
Fsxperimental Technology DSubsidence Control ft. ft a
OC��atrffiXd fiq s'eef ifE.-eFi nSVa ;� .•-
Geothermal(Closed Loop) ®ITracer gp 0 D121)iCU` (� ._. y 'xY
FROM TO D TION(Color,hardness,soil/recktype,grain size,etc.)
Geothermal(Heating/Coolinng Return) nIl Other(explain under#21 Remarks) a ft N).'
if!4.Date WeII(s)Completed:66'2Iy Well ID# ft Qc' ft & „ 'Vick •
5a.Well Location: 35 ft. `, ft 11 " /`?_ 4.0A.-
ft ft
Facility ID#(ifapplicable) ft ft.
Facility/Owner Name �3` [ � L_ 1 4 ,
-1SS v ii _i 4- 'R-h 11 t-1/1'�V S VALE—. ft. ft .l ti.:1./L ' %/E Li
Physical Address,City,and Zip �� _ s-� .o2�
County Parcel Identification No.(PIN) 1.1461.ffi ^A :► r
D'Ii:Cy
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llat/longg is sufficient) 22.Certification:
12•
• Signature of Certified Well Contractor Data
• 6.Is(are)the well(s)(r41''ermanent or DTemporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: }Yes or No with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Con'structian 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 form. 23.Site diagram or additional well details:
8.For GeoprohelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional-well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessarY.- •
• drilled: V... SUBNI FTAL INSTRUCTIONS
9.Total well depth below land surface: gC0 (R) Submit this For All Wells: s form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 22@100) construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: n(b-) 24b.For Injection 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
}1
12.Well construction method: `,'�7 construction to the following:
•
(i.e.auger,rotary,cable;direct push,etc.) II!
. • 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: -I ' "'cc-- 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:af'ei i+"1 NC Amount: el_ completion,of well construction to the county health department of the county
where constructed. .
Form OW-.1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016