GW1--06504_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: t •
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES I 1
Well Contractor Name FROM TO DESCRIPTION I
3572A 7✓',sb ft. i ft. 1
ft. ft I '
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 I D ft 6 1/8 in. sdr 21 .PVC
Company Name
�._ tt0� n (�rl _(� �� 1�^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: w C �0`/�4 t L FROM TO DIAMETER ' THIC ESS MATERIAL
List all applicable well construction permits(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 ❑Municipal/Public ft. it. in.
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0 Geothermal(Heating/Cooling Supply) CYCesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial • DResidential Water Supply(shared) 18.GROUT -
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured it"'•.. •-
-� r ; ',-._,
❑Monitoring ❑Recovery ft. ft e , -',.„,`L_.; V , .,1
Injection Well: ft. ft. NOV O V 1❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) f� r Q
❑Aquifer Storage and Recovery ❑Sal inity Barrier FROM TO MATERIAL EMPIACEMENTIVIETHOD._,__,_ r, r
❑Aquifer Test ❑StormwaterDrainage ft. ft "'" y ��•:3
DExperimental Technology 0 Subsidence Control ft. ft. 1
0 Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color, ards ,soil/rock type,grain etc.)
❑Geothermal(Heating/CoolingRetum) EOther(explainunder#21Remarks) size
0 ft. lid ft. rt
4.Date Well(s)Completed: KO 1 124 Well ID# L•(/ft. 7' ft ,����n',J /`v
5a.Well L ca io ft 1 as ft ,b'7 N M Lv vlA[ l i
f/uY lh• •al
aft. (0D ft
Facili / nre • Facility #(ifapplicable) ft. ft. (911A44 ... - .
ty tyID pplt able)
• \J 1 PA,a14 iO i l i2 1 nitWeSint4 ft ft.
Physical Address,Ci ,and Zip (�set ft ft.
art 41D 1-23-lig& 21.REMARKS •
County Parcel Identification No.(PIN) - .
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
b54110 ug N - 7f(n(43?, W 1 0`f0 l act
6.Is(are)the well(s): l iPermanent or OTemporary Signature of Certified Well n -0 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 L1No ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oui known well construction information and explain the nature of the of this record has been provided 10 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 CIosed-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: 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (ft) Submit this GW 1 within 30 days of well completionper the following:
For multiple wells list all depths ifdj(ferent(example-3ge200'and 2@100' 3 P
10.Static water level below top of casing:
Lt 0 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(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 Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Op en-Loop Geothermal Return Wells:Copy to the
(ie.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)
1 Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type: granulated chlorine [,Amount: I / oZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018