GW1--06463_Well Construction - GW1_20241104

WELL CONSTRTJCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
Chris Morgan •
14.WATER ZONES
Well Contractor Name FROM TO 'DESCRIPTION I I
3572A 13ut 13 1
ft 1
ft. ft.
Na Well Contractor CertificationNumber IS.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
Morgan Well & Pump, INC FROM _TO DIAMETER THICENESS MATERIAL
0 ft "21 ft 6,1/8 in- sdrr21 PVC
Company Name C 'V 16.INNER C ING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: i 1V u.- 2 - FROM • To DItE0E R T CIG ESS MATERLeL
List all applicable well canstruclionperrits(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 ❑M cipaUPublic ft it. in.
•
❑Geothermal(Eeating/Cooling Supply) IM' esidential Water Supply(single) ft ft. in.
❑Industria]lCommercial • ❑Residential Water Supply(shared) 18.GROUT
❑ln'igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLA.CEMENT METHOD&AMOUNT
-
Non-Wafer Supply Well: 0 ft• 20 ft bentonite poured
❑Monitoring • ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACIC(if applicable)
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test ❑StormwaterDrainage ft ft
['Experimental Technology ['Subsidence Control ft ft ' .
❑Geothermal(Closed Loop) ❑Tracer 20.IXR]LEINGLOG(attach additional sheets if necessary)
❑Geotheimal(Heating/CoolingReturn) ❑Otlier(explain under#21Remarks) FROM TO DESCRIP ON(color,hardness,so0/rocle type,grain size,Ste)
1 �` ft 1 S ft Nr, ,� ,,
4.Date Well(s)Completed:1 O2-b 12.� Well)D# ``,� ft. ��ft ►��••//1 �IyU('�\Y ��(�.`C C,
5a.Well Location:
l/ ft. ft �J
J0r lQ 4 r T Af-MN( ft. ft . .., _ ., •.
Facility/Owner NNa`mey���//��C�• ^ • Facility ID#(if applicable) ft ft. 1;-.�. �, .�,ury` 1
• NO'oCSUnvI�OV ffcr ip 1(S ft. ft
ft ft. NOV J 23-
24Ph ical Address,City,and Zip
a ✓oi U 2LRFMARt4 in`_ .. _. .'. i_ "_ n.
I::
�.. ;a....,y
County Parcel IdentificationNo (PIN) D'7u;,u'�r_ru
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well Boll 1)d,('one lat./longis sufficient) 22.Cer• c ti n•
3St�k(Qal N — $0•S133-7 w /0 Z
4
6.Is(are)the well(s): MPermanent or ['TemporarySignature of Certified Well Contractor Date
By signningthisform,I hereby tang that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑•Yes or llNo ISANCAC 02C.0100 or ISq NCAC 02C.0200 Well Constrtwlion Standards and that a copy
gilds is a repair,fill out brown well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or 011 the back of thisform.
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 n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .. 00 (ft.) ..
For multiple wells list all depths ifd(erent(example-3( 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
0.Static water level below top of casing: S ( ) Information Processing Unit,1617 MSC,Raleigh,;NC 27699-1617
If writer level is above casing,use"+"
II.Borehole diameter: 6 1/8 (i) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(I(JC)
rotary Program,1636 MSC,Raleigh,NC 27699-1636 r
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,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) 12 Method of test:
air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine '6�
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental.Quality-Division of Water Resources
Revised 6-6-2018