GW1--01578_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information:
Chris Morgan
14.WATER ZONES." , .'
Well Contractor Name FROM TO DESCRIPTION
3572A I40 ft. !sr ft.
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased Wells)OR,LINER(if ap licable)
Morgan Well & Pump, I I^1 V C FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 10 ft. 6 1/8 in. sdr-21 PVC
Company Name
2.Well Construction Permit#:
�5(4 16.INNER CASING OR TUBING(geothermal closed-loop)
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 :_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mum ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1Da<idential 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: 0 ft• 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19. RAVEL-PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMSAND/GRAVEL
D/G 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) ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
{ l © ft. apc ft. � Ctaltt
4.Date Well(s)Completed:2 161 h 1 Well ID# ft. Lie. ft. growl, Me
5a. o Well Location:
('►
63 ft. ors ft. arai /' •
f••\as IA RiA4A6 ft. ft.
Facility/Owner Name Facility ID# if a licable ft. ft. [ - < '�+,/ c
C1o2o Ivy `i - I S2 elY( wWeil ft. ft.
Ph isicall Address,City,and Zip
-in t'J< ft. ft. i�A K 024
2LREMARKS •
County Parcel Identification No.(PIN) 0:10.1 OC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/loonng is sufficient) CO (� /� 22. tificat• n:
'S ,L' 1(V$ N " DVi �r�13 W Z.-29'
6.Is(are)the well(s): l lPerrnanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer•tifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CI No ISA NCAC 02C.0100 or ISA 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
/�
10.Static water level below top of casing: i (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+"
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-Loop 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
13a.Yield(gpm) Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine P0•1
13b.Disinfection type: Amount: rat
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018