GW1--02908_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-.1) For Internal Use Only: '
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3572A ik ft. IA,a ft ;
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Morgan Well & Pump, I N C FROM TO DIAMETER I .THICKNESS MATERIAL
0 ft. Lk2 ft 61/8 in'• sdr-21 PVC
Company Name t
�� �� vV�� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#. Do ,0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(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 ❑M icipal/Public ft. ft. in.
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OGeothermal(Heating/Cooling Supply) 34sidential 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.SAND/GRAVEL PACK(if applicable)'
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❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test ❑Stormwater Drainage • ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
© ft. 2A9 ft. 6,�^
4.Date Well(s)Completed:4\2\-14Well ID# /a` ft. /1 S ft 1 r u Y'n^;_ Ann -
5a.Well Location: �1 (0 ft.
'J2S ft 1Jr 11""9, tei--c
cAet l\,i1tVI ► • ft. ft.
Facility/OwnerFa/ Name 1 I Q • Facility
]D#(if 1applicable) ft ft. s7�
'N"l 1a I 1 1 J 1X Qal 1-rn,r I I U/v(B 41 ft ft. ,.;...C.•�1...,i`i t ?r.�4
Physical Address,City,and Zip y r ft. ft. MAY A V 1 (1, Q
/'/f (.,/( }q A V 21.REMARKS
IVIFIJ ���,
County D� �L Parcel Identification No.(PII� . iTrfvtit•.i?s`F. '"r.f.', -,;y t 1 i)i
• LP• rC..`ii'Chj
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
C�field,one lat/long is sufficient) 22.Cer' cation: ` /
351140sl N _ � 0tsto ®-7q W (t
l /
6.Is(are)the well(s): ClPermanent or OTemporary
Signature of Certi ell Contractor Date
By signing this form,I hereby cer10,that the well(s)was(were)constructed in accordance with
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7.Is this a repair to an existing well: ❑Yes or EnNo 15ANCAC 02C.0100 or 1SANCAC 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:' 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 3 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wills list all depths if different(example-3@200'and 2@100)
/1!l (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"+'
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 i 7699-1611
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granulated chlorine Id/v./13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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