GW1--06521_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information: • •
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION I
3572A I so". 1St ft. I 1
ft. ft. I •
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)'OR LINER(if a licable)
Morgan Well & Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL _
Company Name 0 ft. l ( Q� ft 6 1/8 in.: sdr 21 .PVC
9 331t1 16.INNER CASINGG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ./ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
-
3.Well Use(check well use): it ft. in. ,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑IndustriallCommercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it' 20 ft. bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well: ,
ft. ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable
)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
• ❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color, ardness,soillrack type,grain the,etc.)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) V/]lJ
a p' l {� ft. 0 ft. `�
4.Date Well(s)Completed: 1 0[�5 I Z-1 Well ID# 2v( ft. i ft V
only d1
5a`Well Location: Li' ft n �.q� ft. 9r0/3,912,04174tP
1 !
1 Rat liktut Due l ft. (�� ft.
Facility/OwnerlN ��I�VV`���"' • Facility1D#(if applicable) ft. ft .• v
•
• C 2 J kau I UYV p6 Lava k4NV1)Ne't/r ft. ft. •
i. '
Ph steal Address,City,and Zip ft ft. �/ (]
21.REMARKS ''" ' 4 2"2 4
Aiin 2��-l�q •
County Parcel Identification No.(PIN) ln`-,,,,..�, -, % !; ,':
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: " ,r
(if well field,one lat/long is sufficient) 22.Certification:
3SiSbi13D N --ni I -)3 W _ . to 1st .4`
6.Is(are)the well(s): I±IPermanent or OTemporary Signa a of Certified Well Contr Date
•
By signing this form,I hereby cer•tij that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 154 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,j111 out Mown well construction information and explain the nature of the of this record has been provided to the well owner:
repair under#21 r•enunis 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: 24.SUBMITTAL INSTRUCTIONS
n n i
9.Total well depth below land surface: SO _ (ft)
For multiple wills list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
i
10.Static water level below top of casing:
0 (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use"+"
11.Borehole diameter: 6 1/8 (�) 24b.For Injection Wells:Copy to DWR,;Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota rY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,directpush,etc.) county environmental health department of the county where installed •
I
. 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
0
ranulated chlorine
13b.Disinfection type: 0 Amount: tr ... `
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018