GW1--02194_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-.1' For Internal Use Only: I
1.Well Contractor Information: • I
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3572A zgoft. at( ft i
ft. ft. ! .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER l THICKNESS MATERIAL
0 ft• 11 ft 61/8 iri• sdr-21 .PVC
Company Name 1 J n 16.INNER CASING OR TUBING(geothermal closed-loop)
'
2.Well Construction Permit#: `k Z,`0(V2_ FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ini
3.Well Use(check well use): it ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. ! •
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Inigation ❑Wells>100,000 GPD , FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft bentonite poured
OMonitoring ❑Recovery ft. it
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 El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. CItJ ft p� t
4.Date Well(s)Completed: 11a I9L.
WellID# 96 ft• .-7a it 1[ .AA_ `
5a.Well Location: 1 ft Zkd ft 6.n C -
t ! C-
ft. f
Facility/Owner Name • Facility ID#(if applicable) ft ft. V't.4,,,...L_'L,-, 1 11 '�-P tr^.1.
• 13105 CAp aye p„. Sets , ft. ft APR O g Z024
Physical Address,City,and Zip /� f� �j ft. ft.
1�Wv tNh� . V 0. O I 21.REMARKS -.,- � .:...�, . •I r
f rli.c ri.X.:�-1. •r
Li�fd!.l;:i'JV
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p 22.Cer/tif y ation
5.6(1q( N 0o• 3 W ( 2-05 N
6.Is(are)the well(s): llPermanent or ❑Temporary Signature of Certified ell Conkac[or Date
• By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15ANCAC 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 faint.
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'r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2.(n 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@a 200'and 2@100)
)
10.Static water level below top of casing:
6 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 1/8 (i) 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,00I0 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Z0 Method of test: air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine - i'yt
13b.Disinfection type: Amount: U
a.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018