GW1--07853_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Chris Morgan 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3572A 1pcft. I� tP ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
MorganWell & Pump,m , INC FROM TO DIAMETER THICKNESS MATERIAL
p 0 ft. .1 L. ft 6 1/8 in. sdr-21 PVC
Company Name
3 n 2 _ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V I �J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
•
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Lesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft* 20 ft. bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. •
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION tcalor,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Otther(explain under#21 Remarks) 0 ft. t4 C ft. Ire ,) ,rye / / jam
4.Date Well(s)Completed: I ` I v 0h3Well ID# 4 t ft. I l.- ft. UU� D V``f S.1 U-
Sa.We Location: 1/1(� ft. /L`�!dl ft /}l� 5rn '^ j J
4, sk",-° Y/l{( ft. W ft. `7�/l (/(/;-t'l 1 J `-
Facility/Owner Name Facility ID#(if applicable) ft. ft 1: _
` ft ft. R; -�1 i \_/ED
1 a�0 C.o� -C. �.�t NC?-BAP
Physical Address,City,and Zip ft ft. n F C '0 5' 2023
f� S) , ^ ( 21.REMARKS
tiU y\J(�J� 1 Inior.ms.ticn Procaavin.2 lrt4N
County ParcelldentificationNo.(PIN) • pCrv. 04e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: i
-5S,logitps- N `n t (nl�0•3 W ‘ 1 Bolan
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certiA)that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q 00 (ft.) Submit this GW-1 within 30 daysiof well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form.to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
I
12.Well construction method: rotary 24c.For Water Supply and OpenLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing'over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh, 27699-1611
13a.Yield(gpm) 2' Method of test: a i r granulated chlorine Y(''�(
13b.Disinfection type: Amount: O
n.....,rsnr_r Nn,th Carolina Denartment of Environmental Oualitv-Division of Water Resources Revised 6-6-2018