GW1--06011_Well Construction - GW1_20241011

1.Well Contractorinformation:
Garrett Clause 4 © tit=W ,: ar =P-.,- �; .
OM itik0 DESCRIPTION t
Well ConlracterName .. P ft. ft.
'4550-A •
ft ft t
NC Well Contractor CertificationNumber 11 1; : .--k'-4 t--.--g" - i07 IE a sfin'_lie 1 e '�`•w " =
OD�I�C-zCuS_IN,G,(fnt`.,m"`"lu lcase�-vY��-'�� >Z C Ja.,.__-.�.:�.
Morgan Well &Pump, INC FRo To DrAMF. _ TffiCIQ1FSS MATERIAL
•
CompanyName 5- n A \ ;16�.I 17krG:08711 0=F (g 1Iirma•regagli .�;=i a••"a_
p Y O FROM TO DIAMETER THICKNESS MATERIAL
2.Well ConsfruciienPerrait#: l fg � in. � � •
List all applicable well consintctionpermifs(i.e.UIC,County,State Variance etc) i '
it. ft in.
3.Well Use(check well use): _
Water Supply Well: FROM TO ESMEETFR SLOT THICKNESS t4reTFurer.
unicipal/Public ft ft m
•Geothermal(Heating/Cooling Supply) r 1I'esidential Water Supply(single) ft f in
I Indusir al/Commercial ,_,�1Residential Water Supply(shared) _rw-:r-.� r• s •+ :r`==+q:z,
1S� D(IJr :ui� F h t rs 3 gib- -.r
IIIij,*ation '"'-) i)•"'%,•, FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Snpply�'4y_e111<,•;?i..:. . t' �,C�,, ft ft n t �U�
Non-Water
r - r��2 ecovery ft +""
Injection Well 01 1 •,ye•: ft ft
11•. / Recharge azge ;: .: - DGsotmdwaterRemediation �:aYQ � A;R(��plicblOrWine� .�-�at Lh�am,�•Z:
*iAquifer Storage;andXZCcovtery"a°;,':t''SDI Salinity33amer FROM To MAT-REM DMPLACEMENT METHOD
;,Aquifer Test 0 Stonnwater Dzainage ft ft
•Experimental Technology DSubsidence Control ft. ft. ' •
•
Geot (Closed Loop) ®1 Tracer ?��2..D'N5It1 t igftaitae�'"riad3ifi$na:ih eiseecessa - =�`w=p . k='En',
�i hPrmal "
FROM TO DESCRIPTION ass,
hardness,so8imcktgpe,grain size,ate)
I Geothermal(Heating/CoolingRetnm) f Other(explain nnder#21 Remarks) Oft. 2. ft :r�
r
....- ft J ft
Well(s)4.Date a Completed: I" ^Z'�l wen.DV OW n it
. -
5/, ft. 6`� ft Pee ck . .
(W`e`Il-Docaizon: -.P ft. ' lot
/�rt/ sra^•
Ca 1 N� ��� �r (7 ft ft
Faciity/OwnerName FacfiiiyID#(ifapplicable)
2s 8 f4v6uc G r Shy .11):,11- • ft.
ft.
Physical Address,
(City,andrp �,iy/ J(�/�/) //�G
TCe`k\ •/ — • —f 41 .' 1. T.,, ft._.+.,,,,,`w,s,,. ..;._- r, 'Yz Yi•p w.Am c g.,— f.
County Parcel IdentifeationNo.(PIN)
5b.Latitude and longitude in degrees/mmuteslseconds or derirnal degrees: '
(ifwell Eel nelat/long' cient) 22.Certification: •
s- one N 6
1• r7c(71 • A.W S�k.� .e� .o
• Signature of Certified Well Contractor Date Zr
• 6.Is,(are)the well(s) ''ermanent or DTemporary - •
By signing this form,I hereby certify that the wells)Was(were)coesbucted in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or(Sri NCAC 02C.0200 Well Canitruction Standards and that a
Ifthis is a repair,fillout known well contraction vfonnation and explain the nature of the copy of this record has been provided to the well owner.
repair antler#2I remarks section or on the back efthis farm 23.Site diagram or additional well details:
l Wells havingthe same You may use the back of this page to provide additional well site details or well
B.For Ceoprobe/DPT or CIos3 Loop Geothermal
- construction,only 1(3W.-1 is needed Indicate TOTAL NUMBER of wells
construction details. You mayaleoa rhndAifionalpagesifnecessary-
(trilled; --' I8'° 5 U13MITTAL INSTRUCTIONS -
9.Total well depth IIelow land surface: `Q (it) 24a.For All Wells: Submit this forest within 30 days of completion of well
For multiple wells list all depths jfdifferent(example-3(tr�2ta0'and 2 l construction to the following:
10.Static water level below top of casing: o ( ) Division of Water Resources,Information Processing Unit,
7fwater level is above casing use"-F" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: (1-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
} `� •above, also submit one copy of this font within,30 days of completion of Well
12.Well construction method: `��) construction to the following:
(i •
.e,auger, cable;direct push,eto.) III • I
Division of Water Resources,Underground.Injection ControlProgram,
FOR WATER S OYPLY WELLS ONLY: ' 163 6 Maii Service Center,Raleigh;NC 27699-1636
13a.Yield(gpm)' . Method of test: {'f C ?CO'�`' 24c.For Water Supply&Iniection Wells: In addition to sending the fora to
/J the address(es) above, also submit one copy ofj this fort within 30 days of •
13k Disinfection type:L.'1rr , " C I S Amount: `dZ' completion of well construction to the county health department of the county
where constructed.
Foam GW-1• North Carolina Department ofBmuonmental Quality-Division of WaterRes purees Revised 2-22-2016