GW1--02851_Well Construction - GW1_20240510

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I •
1.Well Contractor Information: • •
Chris Morgan 14.WATER ZONES I
Well ContractorName FROM TO DESCRIPTION I
ft. ft.
3572A ft. ft.
NC Well Contractor Certification Number INC
CASING(for multi-cased wells)OR LINER(if a licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft• ?Z ft '61/8 in•I sdr-21 ,PVC
Company Name -
� 16.INNER CASING OR TUBING(geothermal closed-loop)
(
2.Well Construction Permit#: l d1 45 Z 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 OMunicipal/Public ft. ft. in.
•
❑Geothermal(Heating/Cooling Supply) 1f esidential Water Supply(single) ft ft. in. ,
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
❑lirigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
DExperimental Technology 0 Subsidence Control ft. ft. ,
❑Geothermal(Closed Loop) • DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) la.
u O ft. Ito ft. fv 1JJ
4.Date Well(s)Completed: Li47-2t( Well lD# ill ft. 63' ft rawitt sQ,t�"�_( -
. 5a.Well Location: 66 ft. J L.rS ft. /� ei v tkeAtiG
(Ak (to, Sl1Q`(s ft. ft
Facility/OwnerN re • Facility ft. ft. :
qakeOr G ft ft. t
Physical Address,City,an p V ft ft. NI IY 1 0i 2024
a'^ Z b`A A,(7 21.REMARKS
V` f� V
County Parcel Identification No.(PIN) r`' "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.zz atio
N O - f l(J� I�2C W �'30-ZY
t� O Signature of Certi e11 Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing this form,I hereby cm*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or [lNo ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oui known well construction information and explain the nature of the of this record has been provided to the well owner:
repair under#21 rentarkx 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:1 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'and 2@100')
`8 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"+"
11.Borehole diameter: 6 1/8 (in) 24b.For Injection Wells:Copy to DWR„Underground Injection Control gm)
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) 0 Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine �1
13b.Disinfection type: Amount: 0 l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i ' Revised 6-6-2018
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