GW1--03417_Well Construction - GW1_20240610

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 6 ft. 3 .' ft
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(far multi-cased wells)OR LINER(if applicable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL.
0 ft. l.,O ft 6 1/8 in. sdr-21 PVC
Company Name
__.-- e'.w._ .. . . ..Cu �cu a-.m�C�f^� ...._v,ram~.� __.e ir, !.._®r.0�.Is .ate •t o._i. ''Ill' __ —_ _--- —
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. hi.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft ft. in.
•
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMpLACEMENTMETHOD&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)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 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) II Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness,soil/rock type,grain size,etc.)
0 ft. to ft girt, C tl
kj,
4.Date Well(s)Completed:S�'-24 Well DMz 1 ft. Li� ft 6' /;vct
5a.Well Location: ft ft Vl "'iiiPPP
611.a /�I' � ft ft. `q
ac /�T6 ft. ft. 1 I Ls Li Facility/Owner Name 1 tF1acility ID�#r(if applicable) /, L. %V` �
13r<i�5 CUl�,c.4. 6 0 k ;1,1 L WC ft. ft JUN 1 Q 24
Physical Address,City,and Zip ft. ft. yam... ,
Cab�rrvs 21.REMARKS ^ 111/+sue • 1
+'�County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,tone lat/long is sufficient) to
,n 22.Certification:AA '3S l 4-10 0 N `n i 311?I to w al- JVt/ IS 21
6.Is(are)the well(s): lPermanent or ❑Temporary Signature of Certified Well Contractor Date I
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 ftNo ISA NCAC 02C.0100 or 154 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 remark 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.
lled'i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1460 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wills list all depths ifdifferent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (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(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24e.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) air Permit Program,1611 MSC,Raleigh,NC 27699-1611
2. Method of test:
granulated chlorine at,13b.Disinfection type: Amount: fff///
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018