GW1--02188_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: .
Chris Morgan •
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION, '
3572A Zgo ft. M ft
ft. ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Morgan Well & Pump, N FROM TO DIAMETER 1 'THICKNESS MATERIAL
Company Name 0 ft. ft*16S 6 1/8 in: sdr 21 PVC
3 Q, ,��� 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft ill.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) +8'Residential Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Mitigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. it.
❑Aquifer•Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology 0 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.)
2 © ft. (/p ft. r0 _ / Ci
4.Date Well(s)Completed: t 2112t Well ID# L,I ft. k) ft 12
5a.Well Location: 61 ft (I o ft. nn3 ss�
e kh\ n s cy ft. ?�lyU� ft t,�la %r
C, `r/ CA. Chi�YAh;
Facility/Owner Name • Facility ID#(if applicable) ft. ft
i
ft ft. i h;` �
Physical Address,City,and Zip ft ft APR
p
��w /,.1 ` 21.REMARKS H r f{ (0 S ?ll?4
IP c�•2,� ��a
County Parcel Identification No.(PIN) - •
tilit.ner'..,,t r''. ..;ti.i;: )li"4h
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: irr1 i_r•'.i:7c:
(if well field,one lat/long is sufficient) 22.C • cation:
350 2S' N --Z.,37uCf W _2-S.-
Signature of Certified ll Contractor Date
6.Is(are)the well(s): InPermanent or OTemporary
•
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo ISA 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 remarlx 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:t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32-5 (ft)
For multiple wells list all depths if different(example-3Q200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
�© (ft 24a. For All Wells: Original form to' Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If water level is above casing,use"+" I
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 500,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) j Method of test: air
granulated chlorine �g 1
13b.Disinfection type: Amount: 17 CrL
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018