GW1--03408_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan •
14.WATER ZONES
WellContractor Name -
FROM TO DESCRIPTION
ZOO ft. Zo I ft.
3572A
ft. ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR LINER Iif a licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft• I55 ft 61/8 in. sdr-21 [PVC
— 4 Namt< - - _ - .... -
i►tl" s
_- `- - •— - — cR[—__ re--- =DI TER rn3c-zt3Vir.Ss—=h 2E3fI Y.-- _---,-
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 ❑Min ipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) L41Cesidential 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
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer 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) El Other(explain under#21 Remarks)is
FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
O ft. C.o ft. -►,idyl /!e
4.Date Well(s)Completed: 2t1pis We11ID# C.j( ft. ' ) ft s'-►4 k
—
5a.Well Location: fP' ft. .M_ s+ J,��G
aftkiAcA-G� S� ft. ZZS rt. 1 /l�a►� N�x�;� .
Facility/Owner Name • Facility ID#(if applicable)
ft. ft. (J1
INgt N0II eti LA. %coil'Its FoA j NC-
ft. ft ,
Physical Address,City d Zip ft. ft. .+`` `/ iV `L f
r al'_ ,\rA_ 21.REMARKS '
County Parcel Identification No.(PIN) V ���
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: k� ,f,,,.! P'C(. u
(if well field,one lat/l�o o is sufficient) 22.Certification: 0 ,Qf3OG
3S r 61O Q ) N " �, 01-1 a33� w
Ul /S...,
6.Is(are)the well(s): IhPermanent or ❑Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby cent&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l lNo 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:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22S (ft.)
For multiple wells list all depths if different(example-3 a@200'and 2(100) Submit this GW-1 within 30 days of well completion per the following:
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft 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 ( ) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota rY
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) I2 Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
J
granulated chlorine X O_
13b.Disinfection type: Amount: LLUJJ
Foram GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018