GW1--03234_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W_qU Contractor Informs o /�
C\QuSe- 14.WATER ZONES
FROM TO DESCRIPTION
We�ntractorName
gyp}. tiS ft. ft.
�/ ft. ft.
NC Well Contractor Certification Number A TO 15:OUTER CASING for multi-cased wells OR LINER if a licable
Morgan Well & Pump, INC C FROM DIAMETER THICKNESS MATERIAL
1 fL1 (o ft• 61/8 in SDR21 JPVC
Company Name
/1n N � Y► �� 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: \ C� l ooM T° DIAMETER 'THICKNESS 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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Miesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DE§CRIPITON(color,hardness,so"' ack a in size etc.)
U ft. (:) ft. s
4.Date Well(s)Completed:'p�2� Well ID# C0 ft. ® ft.
S.a�.Well Location:
/ , C3ft. ft. O C�
1/O/1/1�1X3d"la^ '7 ft. ft.
Facility/O�wuer Name Facility lD#(if applicable)
�� 1 z/ ��f� SCII t S '�'.cOA
Physical Address,City,and Zip ft. ft.
21.REMARKS + , 1 `
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.J
(if fie] laUlopg' ufficient) � 22.Certification:
6.Is(are)the well(s): CJPermanent or ❑Temporary ature of Cert fled Well Contractor 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 11No 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction 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 remarks 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 G�-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 completion per the following:
For multiple wells list all depths if different(example-3@200' 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
f 0.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (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 Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,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
le a i r pressure
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: p
q13b.Disinfection type: granulated chlorine Amount: I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018