GW1--03474_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: - •
Chris Morgan • 1a.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3572A NO 1.411 ft
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(1f a..licable)
Morgan Well & Pump, I N C FROM TO DIAMETER TBIQOHFSS MATERIAL
®� o _�I�e 0 ft`/4, ft 6 1/8 in. sir 21 .PV
t'-' �.. .. _ A.SLI'G OR TI1BL'K e; ----. -_..- -
�- " " ----- -- _=-TItOM =T-t3 DIh11T-ER =TfiICIQSS =hi4TLiSziZ----------
L WCIl I.OIIStYIlctlOri Permit 7f C. l- J-(/_I __ __.__._ -__
List all applicable well construction permits 0.e. C,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 it. in.
•
❑Geothermal(Heating/Cooling Supply) pesidential Water Supply(single) ft ft in.
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑hxigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEIVEENTMET$OD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
OMonitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPI ACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Traces 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness soil/rock type,grain size etc.)
0 ft 46 ft (3,.,.. na
4.Date Well(s)Completed: Well ID# uyt( ft. ft tQ o o 5''a si_o-a-
Sa.Well Location: l6 ft. �`•`-S ftglrn
&M� IO
�e, SineLC3 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. -" -` ' i`
1015 Cuva ,t0.` d�i Li. M est/ ��W-- ft. ft �.�L.: ; ,r
Physical Address,//�� �City,and Zip 1 ft. ft 1 2024
ouic .1 [/3111R (J�C[ 21.REMARKS 1Fiasisi:ettl,r•ea04„
V ijUti
County Parcel Identification No.(PIN) '.0 i Cti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. i.catio
S5.561`A N aO. c877 w .4 $-1 S-Zq
6.Is(are)the well(s): ClPermanent or ['TemporarySignature of Certifi ell Contractor Date
•
By signing thisfo ,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 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#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For tieoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
consbuction,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.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wills list all depths ifdii different(example-3@200'and 2Q100) y P
O 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3 (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
(ie.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 5 Method of test: air Permit Program,1411 MSC,Raleigh,NC 27699-1611
(gpm)
granulated chlorine OZ.
Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018