GW1--06050_Well Construction - GW1_20241011

1.Well Contractor Information: 1 ' • .: . ' •
Garrett Clause `� ' -�r~"k°'' y -„y,' •„
`4.0 ''.S.n= -'...?-.-`:;,�,., z5.�.: = -; v, =. i , .cam- -�.; .
• FROM TO DESCRIPTION
Well Contractor Name .• 5�ft' 1 ft
4550-A it ft ' I ,
NCWell Contactor CertificationNumber fyx©J }XM1HG3(fprmnlli:`cageare71s7rQ i?R�?T `RI(ifni'lieaiMe) S�"�_"_3r,F. •: •
Morgan Well &Pump,INC FROM TO DIAMETER THICKNESS MATERIAL .
ae 1. ft. . ft Y$ in. $PM'\ ?VC.
CompaayNameie. 't6effi `cT'o'sed'1.lib '_"` . %=•,---
•A/ �C.Z� �6a ;c G:o�'�io-131iYr� � �:._x;�'��:�'.'"��E��:�:�-�:
2.Well ConstructionPerM.it#: mot CI^ FRom TO DIAMETER TffiCIENEsS n2AT.ERaT, •
List applicable well construction permits(i.e.UIC,County Sate PariancG eta)
ft • it
ft ft in.
3.Well Use(cheekwell nse): y _
�ri�.,S.�@,L2I'VZ'�l�.L�,�-�Y��'w:��i �`-�'a ra';.�' ��=•�.v'�.£E:-t: ... Z:',s's`-
WateTSupply Well: FROM TO DIAMETER SLOT at*ru' _ THICSMEss MATERIAL
D Agdcultual jMunicipeiPublio • ft ft m.
•.EGeothermal(Eeating/Cooling Supply) &Residential Water Supply(eg e) ft ft In. .
21Tndustrial/Commercial ' IResid ntial Water l shared
e SnPP Y(sharer') f'- �`'nrs��� r:2.�.� t^..� "t5-i`:.�-�?-"--�'�?c2�ek:v�'fi:.���r..,
nru'igai on r•� - �;�-' =^i.'I r�" FROM TO MATERIAL Is14rPLACEMEIQTI�'ETHOD&AMOUNT
Non-Water Supply Well:' . 6 ••it I' ft i,�-� '�U U mL)
T 1 l 1024 coy ft. ft.
(Monitoring (�'{� 1 7- � �Y
Injection Well: GC ,r; ft it
JAquifer Recharge . ?•- '10 Groundwater Remediatlon
• __ ' �v s t. Lali 7v_a =+ .r ,-i •..v .rTM t
DAquifer StoageindRecktery'.
DSalinityBemer • FROM TO MATERIAL EMPLACEMENTMETHOD
.11 . 'er Test DStonnwater Drainage ft ft .
Experimental Technology Subsidence Control ft ft. '
•
0 Geothermal(ClosedLoop) DTracer 00113 O-(aif7.ctaddtidnalsheee 5•eceIgazpj M=; 'M
FROM To DESCRIPTION(color,hardness,soiUmcktype,grain size,etc)
Geothr..rmel(Heating/CpolingReam) n Other(explain under#21Remarks) �l Q g _ \ t� P -
q �j t CJ ,lid 1Jr ;�
4.Date Wells)Completed:-/`'`'?' t Well1D# 3.-ft (�v ft ',� Aa^ V•
..
O
5a.WeIlLo cation:. •
9 ft 32 PvC/ it Bey Cr� it
Ca(1„`. 7:wolfibLy J
ft qq :�c
Facility/OwnerName FadDitpID#(ifapplicable) Y iZc I /U e/ 5 rey 9 rti,
is to F rc4 cry Ce j 5.647 ?o -
PhysicalAddress,City,and Zip •
�. __
_ '_Y"RF1l�A�2TC.4S: %.<=:L:%Y.•=�w=�;=�'_ ::�•�''b�-' i•-',=--'',vrsZ•- = w:f..��<.,•az=;;z�. s:l
County
ParcelldentificationNo.(PIN)�' •
5b.Latitude and longitude in.degrees/mimitrtes/seconds or decimal degrees: • •
(ffwell field,
�one lat/longissi>tiicient) may` • 22.Certification: ' �/ L
SS- y/7 N qI.° . •�'6.• W ...)e��'�'�11�P/ '
�� Ze 2,(
• 6.Is(are)the well(s)ix''ermanent or yi Temporary • Signature of Certified Well Contactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7-Is this a repair to an existing welt: DI Yes or No with ISd NCAC 02C.D1 Do or I5A NCAC 02C.0200*ell Construction Standards and that a
. 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 farm• 23.Site diagram or additional well details:
8.For Geoprohe/DPT or Closed-Loop geothermal Wells lu vingthe same Yon may use the bark of this page to provide additional well site well
or we
- construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER.of wells
conatruotion details. You may also attach additional pages ifnecessary.- •
drilled: h U.BM1TTAL INSTRUCTIONS
9.Totalwell depth below land surface: .57‘b (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multple wells list all depths ifdierent(example-3Q200'and 2@ 100) construction to the following:
10.Static water level b elow top of casing: S75 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use+ 1617 Mail Service Center,Raleigh,NC 27699 1617 ..
•
.11.BorehoIe diameter: 0 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
sr`! •above,also submit one copy of this form within 30 days'of completion of well
12.Well construction method: Ito ] construction to the following.
(ie.auger,rotary,cable,"&rectpusli,eto.) tit
Division of Water Resources,UndergroimdInjection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 11 {7 ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 . Method of test:hi. �[ 10-0t'fr-- 24c.For Water Supply&Injection Welts: In addition to sending the£orm to
�+
//�� the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection Lype:arc,i''I cc Am /�
onn CA, completion of well construction to the county health department of the county
where constructed. •
Fenn GW-1 North Carolina Department ofEnvironmental Quality-Division ofWater Resources Revised 2-22-2016