GW1--04817_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3572A 1tio ft. 14I ft
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan We I I & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. +0 ft. 61/8 in. sdr-21 PVC
Company Name
G Q O 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: LiI J Q o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LIIC,County,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. it in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. In.
DGeothennal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustrial/Conunercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 it bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ID Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
1 I�i Z( p ft. co
ft w11 Cia.
4.Date Well(s)Completed: \ 1 1 Well VII ft. it ft � of
5a.Well Location: l ft its
ft
7 f(Yl v f \A UY1,0 ft. ft . -.
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft. ft
Physical Address,City,and Zip
it. ft. AUG 1 4 2024
IQowa 21.REMARKS
County Parcel Identification No.(PIN) D,I•-- :-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well fief lat/long is sufficient) 22.Ce cation:
3S g1 S N --p. toic o W 4=7-Zy_
6.Is(are)the well(s): lhPermanent or ❑Temporary Signature of Certifie Well Contractor Date
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 IJNo 1SA NCAC 02C.0100 or 15A 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.
filled'r 24.SUBMITTAL INSTRUCTIONS
tee
9.Total well depth below land surface: I (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(4000)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: LIa (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 Infection Wells:Copy to DWR,Underground Injection Control(ItIC)
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
(Le.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) SO Method of test: a i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: az.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018