GW1--06471_Well Construction - GW1_20241104

1.Well Contractor Information: ' I ' I ' I
•
Garrett Clause I a Q s y�`' .- ee _ •
MOM TO DESCRIPTION t
Well ConfraetorName 02 OM ft. �j\ ft
4550-A •
(••
ft ft. ' ,
NC Well Contractor CertificationNumber •
1e-O - �C�'m 117,G:fgr•�mn�lf; i e11s7KO t�_ iiira `liea„ble) x-.�'•`_ =i4^: •
rkll�4S
Morgan Well &Pump, 1NC Ix°M To Dxa /g,max Tom` .ss MATERIAL .
ft' ' kUtift 0) �! In' J�ott\ vvc,
CompanyName 1'63 ''4CSIGOR 1:11• 'tim`e;eged-e 1-- E4r ' c i ;q�r
e ��0702^ TRO.MO DIAEER TEtCIOEss MAT.FTT . .r
2.Well Construction Perm : ft in
List all applicable well construction permits(i.e VIC,County,State Variance,etc) _
ft ft in.
3.Wei IIse(checkwell use): �7 .(�
Wafer Supply Well: 111.01Y1 TO DIAMETER , SLOT Sin' TEIC MESS MATERIE T. •
1 •pimillumal alMunicipal/Public ft. ft. in.•Geothermal(Heating/Cooling Supply) 1il1 Residential Water Supply(single) ft, ft in .
lit T rinstri.a]/Commercial nIResidential Water Supply(shared) `x's° b`.o,m'rz: : 1„:r °=:� `"'. a ;:r41
_ � ter.—<:�:'c,,-
'Irrigation FROM TO MATERIAL L'MPLACEMENT OD&AMOUNT
Non Water Supply Well: • - ® -ft r 11��' ft ,�,i-t,}-L,• '?U m3
Monitoring DifRecovery ft ft. .
Injection Well: ft. ft.
*Aquifer Recharge D GroundwaterRemediation a Iicalile�i u ' �y
ti 5 t1L�T irgle4 Nit �i ii �? aft_•.,. "••n= 3a. s?a:V...�--a-§fer
*Aquifer Storage andRecovery • alSalinity.Bander FROM TO IYILT:RTA7. EMPLACEMFSlTMETSOD
it gniferTest f StormwaterDrainage ft ft .
*$xperunenfal Technology UISubsidenoe Control it. it
Geothermal(Closed Loop)• Tracer 010.B L'.Iil-S0'.00•c(atta$c aria fitillr.s egfr= ecessazj'):3 1.:? ..."i h 4=l ,"=
FROM TO DESL'RIPTION(cast hardness,soil/mekiy4egram size,etn)
Geothermal(bleating/Cooling Rehm) El Other(explain under#21 Remarks) Q �� vj_ ` h`r k-
4.Date Wall(s)Completed: I0'�1' `E/ Well ID# S...a ft 9' ft lipvz 4.r .
5a Well Location: q® ft. 'S"ft '6R,y n V. ch—
�G "1�l,na\I.P
gcft fae6- t . r1.--c./g en ' 3 r4... ke
Facilit lD#(ifepplicable) ft ft.
Facili�,t/y/�O•�wgnerNam�e ` ,� \ � .. _ -^�- `` • `i ........
�/c I ( \ — s/�1�J • ft. ft ,a. 'ii:. ' 1..,
eree.i!
Pfi calAddress,City,and Zip f+ e,,A N(1 V k) 4 2024
z/c.164wcrvs3`1 amEN/ATEfi-`tis�i's:gi.:1:F r amgs-,= :.,.7.uis ;sEatav-2,4.,:Y. c= :=:
C��aWb� .• • , -- , ,. •
ParcelIdecationNo.(PIN) 1f,:. i.f :T' ^.,4� ��?:.
County .D':'J 1 •�V .
5b.Latitude and longitude in degrees/miziu±es/seconds or decimal degrees:
fwel1feld,on lot/long is aixcient) 22.Certification: • -
1575 IC N SO A c(6 'IL W C? - $ c g 202`- .
v ' • Signature of Certified Well Contractor Data
• 6.Is(are)thewell(s),� ermanent •
or MiTemporary •
By signing this form,I hereby cerii5•that the well's)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or To With 15eI NCAC 02C.0100 or 15ANCde 02C.0200 Well Construction,Standards and that a
If this is a repair,fl outinown well construction information and explain the nature of the con'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 Ceoprobe/DPT or Closh Lod (geothermal Wells havingthe same Yon may use the bark of this page to provide additional well site details or well
- construction,only 1 Ci-W,-1 is needed. Indicate TOTAL NU ofwells
construction details. You may also attach additionalpages ifnecessary.
drilled: -- n S uitl\uTAL INSTRUCTIONS .
9.Totalwell depth below land surface: �? (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For muTiipie wells list all depths#di#erenf(example-3@200 .it 2@l00') conshuctibn to the following:
_ 10.Static wafer level b elow fop of casing: d (ft) Division of Water Resources,Information Pro cessing Unit •
Ifwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: j,7(n-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
`r •above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IL° T constructionto the following: I ,
(i.e.auger,rotary,cable;direct posh,eta.)
• • • Division of Water Resources,Underground Injection.Control Program,
FOR WATER S UXPLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 2769 91 63 6
13a.Yield(gpm) [7 ` Method of test: (( 'i MIS"' — 24c.For Water Supply&Injection Wells: In i addition to sending the form to .
��** �t the address(es) above, also submit one copy of this foam within 30 days of
13b.Disinfection type:Giret i1 .16,C Amount: /62 completion of well construction to the county health department of the county
where constructed. -
Form('W 1 North Carolina Department ofBnvuonmental Quality-Division of Water Resources Revised 2-22-2016