GW1--06498_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris Morgan •
x4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION I +
3572A S(�ft. `gip ft
lYft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)GR LINER(if ap ]!cable)
Morgan Well & Pump, INC . FROM TO DIAMETER 'THICKNESS MATERIAL
Company Name fl ft '10l ft 6r1/$ in' � r 2
sd1 ,PVC
`_/r t n o��0� 16.INNER CASINh�GORTUBING(geothermal dosed-loop)
2.Well Construction Permit#: VV 2./� FRM O • TO DIAMETER THIS MATERIAL
List all applicable well constructionpermits(le.IJIC,County,Slate,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 ❑Muunicipal/Public ft ft. in.
❑Geothermal(Pleating/Cooling Supply) residential Water Supply(single) ft it in. •
❑Industiial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT r ETHOD&AMOUNT
Non-Water SuppIy Well: Q ft. 20 ft. bentonite fevered 194/y`(�,� 0 , , i
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Mal inityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. •
❑Geothermal(Closed Loop) • DTracer 20.DRILLING LO G(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) o0 ft TO IA VI. D �TIo� raness,soulrock tsae grain size,etc.)
4.Date Well(s)Completed.:10[33194 WeII ID# "(` t ft. ton ft
‘.0 rg\\V\=IStlYtt
5a.Well Location: �„/) ft -2, lf7 eft
U 1 i c
C� `uuticK ft ft.
Facility/OwnerName • Facility ID#(if applicable) ft. ft. I- \, y .ti
-Ta4 OcICIrr IQ
,r -� . a <,'�:5
Phys�icaalAddrressss,,CCiyandZip QttlVV��/ I ft. ft 0 (��i
I\W`in 1 5�4(4 21.REMARKS
County Parcel Identification No.(PIN) l-:`,A;;.:3 i_
•
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/longis sufficient)
S ` Lite q r3 N - o 22.Cer' cation: .
(ik-k '��1�(S/(
6.Is(are)the well(s): l!Permanent or ❑Tern or �-C W Signature of ed Well Contra i
t�/ 2�
p any Date
•
By signing thisform,Iherebycert(rthatthewell(s)was(were)constructedinaccordancewith
7.Is this a repair to an existing well: ❑•Yes or I'JNo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill Dui known well conshuction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 renmrls section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Leap Geothermal Wells having the same You may use the back of this page to provide additional well constuiction 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.
dulled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: • l..--!AV (ft.) Submit this GW-1 within 30 daysg
For mulffple wells list all depths ifd event(example-3@200'mid 22@11000) of well completion per the following:
10.Static water level below top of casing: UV f£ 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"-h" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
(Le.auger,rotary,cable,duectpusb etc.) 24c.For Water SuppIy 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 100,000c GPD: Copy to DWR,CCPCUA
15 air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1YIetlro d of test:
granulated chlorine 1 1
13b.Disinfection type: Amount: 1�j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1
Revised 6-6-2018