GW1--03463_Well Construction - GW1_20240611

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 260 ft a.) ft
ft. ft.
NC Well Contractor Certification Number INC
CASING(for multi-cased wells)OR LINER(if applicable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft• Li g ft 6 1/8 in. sdr-21 — —
2-:Well Cons uction Perms—t#: =FROM TO =Dry-ER =T>DetcHI+ss ——nAT>Rift —_- _ -
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 ❑ cipal/Public ft ft. in.
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❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑hrigation ❑Wells>100,000GPO 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)
❑Aquifer Storage and Recovery ❑Sal in ity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑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,etc.)
❑Geothermal(Heating/Cooling Return)a ❑Other(explain under#21 Remarks) Q ft ft. !2
4.Date Well(s)Completed: 6 7 Z4 Well ID# Zt ft. Z2,U ft. ,>rrb+�(1
5a.Well Location: ft. ft J oottvvtt��
ft. ft.
WIlktown Edocom.
Facility/Owner Name Facility ID#(if applicable) ft ft.
( 135 Ec ri'er Loop N• 4kwe 61 r ft. ft. (`� `,C •>{ E
ri /
Physical Address,City,and Zip ft. ft. J
QpwAVt 21.REMARKS JUN 1 1 ZOZ4 -
County Parcel Identification No.(PIN) ir. C,t 7^� 4,4-1 u
nit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t a{iw
(if well field,one lat/ gjsluffr nt) — �t 4�.�\°C 22.Certitieati0
35 S1` �11Un N W S—IC 11
6.Is(are)the well(s): llPermanent or ❑Temporary SignalturreeeofCertifie Well Contractor Date
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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 ONo ISA NCAC 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 remarla section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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.
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drilled:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 210 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wills list all depths ifd�erent(example-3@200'and 1Q100')
LI 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: —I 0 (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
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 GPO:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
H
13a.Yield(gpm) Method of test: a 1 r
granulated chlodne II
O Z
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018