GW1--04708_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3572-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
' ft. iyaft. (Q .ir in. sal pVc
Company Name
( -o 6--;i/'.1^ 1 )a 16.INNER CASING OK TUBING(geothermal closed-loop)
2.Well Construction Permit#: i(�OI.O� JJ���v FROM TO DIAMETER THICKNESS MATERIAL
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 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
0Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
ri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft• 20 ft• bentonite poured
Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IDAquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
0Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
0Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
2 0 ft. LID ft. /�(cj1/
4.Date Well(s)Completed:ti 10 r � Well ID# 4' ft D ft. Fes'�.4p Q C
5a.Well Location: el ft. '�!i ft. �'I a w S-a'- ,5
1rtiCilt Skrnon 0:40ft. 9t40ft. elirt`7 %,rcr _
Facility/Owner N. i a Facility ID#(if applicable) ft. ft.
I�7 � is n/� �V,, , ft ft. .
V� 4,.�/� ft. ft. , t'^
Physical Address,City,and Zip
CakAbta 4 i!Ns D69 solo 21.REMARKS v
County Parcel Identification No.(PIN)
Ir,f::,:a,. . 1.r" - a.*
ii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: GvA`y t.
(if well field,one lat/long is sufficient) 22.Certification:
36. (olt1LA N V)•61-l553 W z z.3
6.Is(are)the well(s)DX Permanent or OTemporary Signa of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: LTD SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (J� (vJ (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 43Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Ob Method of test: 1A( ?ret51,16 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: , d G 2. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016