GW1--05719_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: I
Chris Morgan I
14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
3572-A 375 ft• 376 ft. ' i
ft. fL 1
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. Li g ft 61/8 in. sdr-21 PVC
Company Name ,
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Zd 23 011 W FROM TO 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipallPublic ft. ft. in.
OGeothennal(Heating/Cooling Supply) 'Aesidentiai Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑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.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
DExperimental Technology ❑Subsidence Control ft. ft
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ,ft. z a ft. Y h et _
�'23?,3 ` ow /� , t1�
4.Date Well(s)Completed: Well ID# Z l ft. S�d ft. /! �J�Ypn,] _,
5a.Well Location: ft. ft. V► T�J
� GV.kIY� ft. ft. s i-rt. .:
Facility/Owner Name n-1 Facility ID#(if applicable) /� ft. ft. L.j V tP 3
S1 ' Tvcker}�0w1'n tom. NQIAI ertEgC ft. ft. SEP d 5 2023
Physical Address,City,'and Zipft. ft.
L 21.REMARKS i►lr`trrp:n<?_� �..Y::,�;f r .
MallTa,Ottkl.l �s3^o0'3q^ v! ..).-t'c:ieEl 3 fir.;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secondsor decimal degrees: •
(if well field,one lat/long is sufficient) 22.C motion: '
3S.'19 00 N 10• I600 W ,.........,,,,,-"' 17-30
6.Is(are)the well(s): ClPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer•hfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l'JNo ISA NCAC 02C.0100 or ISA NCAC 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 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: 596 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4200'and 2@100')
S`� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) 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 to1DWR,Underground Injection Control,(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
M1 12.Well construction method: 410.11
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2. Method of test: a j r Permit Program,1611 MSC,Raleigh,NC 27699-1611
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granulated chlorine `7/O.L ,
13b.Disinfection type: Amount: --
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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