GW1--06462_Well Construction - GW1_20241104

i •
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: , •
1.Well Contractor Information: .
Chris Morgan • 14.WATER ZONES
We1lContraetorName FROril TO DESCRIPTION
3572A
^1 OS ft. 1(r?ID ft
lbJcft (A04).ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
Morgan Well & Pump, INC FROM TO DL4METER THICKNESS MATERIAL. •
-0 ft gS ft 6,1/8 hisdr 21 PVC
company Company Name
C 1 ' - ►V ^ n�,(_ 16.INNER CASING OR TOEING(geothermal closed-loop)
2.Well Construction Permit#. !((J(�1 FROM • TO DT4R THICKNESS MATERIAL
List all applicable well consiruciionpermits(a UIC,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 ❑Muunicipal/Public ft ft in. -
CI Geothermal(Heating/Cooling Supply) Mite/sidential Water Supply(single) ft ft. in. • -
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL 'EMPLACEMEPIT=TROD&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 ❑Salinity Barrier FROM TO MATERIAL EMpLACEt41ENTMETHOD
❑Aquifer Test 17Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
0 Geothermal(Closed Loop) ❑Tracer 20.DRIIIJNGLOG(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) FROM TO DESCRIPTZOI�*(color,hzraaess,soiUracktypegra;n,;Ze,ete)
rr�� �y ft. 2S ft. YLU,,]l Ca(��(/Aj
4.Date Well(s)Completed:'O101a lag, Well ID# Z ft. 2 ✓p91ft q ,t ]
5ra WeIILocatiott: �R. ft �!
1 e(\ ft ft.
Facility/Ownery1Name ��//���"� V/�1 ` �• Facility
(I/D�#�(if
f(applicable) ft, ft. ` o`- i';
"1"1`•1G zi lAtok' Zd 1W[r PI DS 'Ct ft. ft. .. . . i,,_
Phy/siicalAddress,City,andZip ft {t NOV4 LG21f`
/I Iat1,y1/ i f 21.REMARKS -
County M r l/`J� Parcel Identification No.(PIN) -irr`..::r•-...r •. :?`:
A'iui.�'11',t✓ta
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is ouoient) 22.C cation'
3s4143OC N -VD 1tfloSci W
• 1o13"
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Co or Date
-•
By signing thisform,I hereby cent fy that the well(s)was(were)constructed in accordance.nth
7.Is this a repair fo an existing well: ❑Yes or I iNo ISANCAC 02C.0100 or IS.ANCAC 02C.0200 Well Conshuction Standards and that a copy
lira.is a repair,fill our known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarls 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.
drilled:1
2�D (ft.) 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wills list all depths ifd�erent(example-3@200'and 2Qa 100) Submit this Gs within 30 days of well eomple$on per the following:
10.Static water level below top of casing: 30 (ff) 24a. For AR Wells: Original form to Division of Water Resources (DM),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DM,Underground Injection Control(IOC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
(i.e.auger,rotary,cable,directpush,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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) Method of test:
a I r Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine 2-0�
13b.Disinfection type: Amount: I
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018