GW1--06502_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor Information: I
Chris Morgan 14.WATER ZONES II
31572ArName
ft.1,04 , TO DESCRIPTION I
1,3k ft.
NC'Jell Contractor Certification Number ft ft. I
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Morgan Well & Pump, INC FROM TO DIAMETER 'THICKNESS MATERIAL
Company Name 0 ft ft 6r1/8 in (Sdr 21 .PVC
((����(( ��(( (� 16.INNER CASING OR TOBING(geothermal closed-loop)
2.Well Construction Permit#F�V�I L0'(0?TOSS FROM ' TO DIAMETER THICKNESS MATERIAL .
List all applicable well constructionperntits(i.e..UIC,County,State,Variance,etc.) ft ft. inMATERIAL
3.Well Use(check well use): ft ft in
Water Supply Well: 17.SCREEN
.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) grrcesidential Water Supply(single) ft ft. in
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wafer Supply Well: 0 ft' 20 ft bentonite poured [T. '- -;-.
[Monitoring ❑Recovery ft. ft ,.•,.... ' ' ' - t
Injection Well: N. "
❑Aquifer Recharge ❑GroundwaterRemediation ft.
NOV 202/
❑Aquifer Storage and Recovery ❑SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPI A(IEMENI`MET'HOD.'„^,;-a la-,}1
❑A er Test
❑Stormwater Drainage ft. it ,D..,, ,,'j;J�le. a
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) • ❑Tiacer 20.DRILEING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks)
FROM TO DEscRipTlo�c¢otor, oath sail/racktypearaiaszeet�)
Q Ir� O ft. 1 r 0 ft i l' (^ ' � �
4.Date Well(s)Completed:101 Iif1 1 Well ID# Lk k.ft. sKnI.J ft )Y1 C��+•�1 e �`-C.,
5a.Wel1Location•- g.( ft. Ai _„Dft pl rt ,
l Q . ft. ft s1(M�" 9
I
Facility/OwnerName////e • Facili Ilk If aapplicable)
ft ft.
• kW 0 VV Pv - 1 II 0/1 1rW reS14 at ft ft.
Physical Acn 3r s, '+,and Zip (( ft ft
` 1 di) i I wcki1,.(, ,o-DO 21.REMARKS .
County 'Parcel Identification No.(PIN) 1 -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/lono is sufficient)
22. tification:
3Si6. gS Ns''‹v.1C62. 36. W .
Signature of Certified We actor 1 O 13 I 12E1
6.Is(are)the well(s): ClPermanent or ❑Temporary g° Date
•
By signing this form,Ihere y cern),that the well(s)was(were)constructed in:accordance with
7.Is this a repair to an existing well: ❑Yes or I•INo ISA NCAC 02C.0100 or ISq NCAC 02C.0200 Well Condi:tction 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 rentarls section or on the back of fliisfonn.
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 additionalpages if necessary.
•
drilled:r
P 0 (ft.) 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths ifd Brent(example-3(a�00'and 2@1009
yp
10.Static water level below top of casing: L•0 (ft.) 24a. For All Wells: Original form to Division;of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 24b.For Injection Wells:Co to D (IUC)
On)
Program,1636 MSC,Raleigh,NC 27699-1636 Underground Injection Control
12.Well construction method: rotary
(Le.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) 6 Method of test: air Permit Program,I6I1 MSC,Raleigh,NC 27699-161d I
granulated chlorine \0 0
13b.Disinfection type: Amount: (..
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018