GW1--05750_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan . 14.WATERZONESI
WellConhactorName FROM TO DESCRIPTION'_
30c ft. so; ft. 1
3572-A ft. ft
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
Corn an Name 0 ft. L j(•j ft. 6 1/8 'in• sdr-21 PVC
P y
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 11Z Lea 1 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 ❑Mun'cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) talsidential Water Supply(single) ft. ft. - in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,18.GROUT
' ❑Inigation ❑Wells>100,000GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured _
❑Monitoring ❑Recovery ft. " ft. I
Injection Well: ,
ft. ft
❑Aquifer Recharge ❑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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) _
2 O ft. 5 ft. tornAjtEt2
��4.Date Well(s)Completed: g-S�2,3 Well ID# b ft. 35ft unk il""C-
5a.Well Location://r► ?� ft. S� ft. /Ixr]
j Q11145 6i0.1 n5 c� ft. ft. �1 !,`c- .
Facciliity/fOwnerrNName /�(, Q Facilityt ID#(if applicable) ft. ft ,. �,. .., ^p
tD ILI L Ziat Ch•1`�-• Q1�1 v� ft. ft i �„� i v�� l
Physical Address,City,and Zip ft. ft. 1 F p n
Cl�'e-� 559 y 6 21.REMARKS s`{ :i 5 2 tI ZJ
County Parcel Identification No.(PIN) Infori , r,vn ?f;-c• +7,1Q L44/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a4trQ/
(if well field,oner lat/long is sufficient) ' 22.Certifrcatio
fw 35.3 5.5 p�N 6 I.SZ g W a
J��Zf/-23
6.Is(are)the well(s): l lPermanent or ❑Temporary Signature of^ertified Well Contractor I Date
onl
I
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or EnNo ISA NCAC OW.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 I 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: 5Qo (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'and 2@100')
24a. For All Wells: Original form Ito'Division of Water Resources (DWR),
10.Static water level below top of casing: go (ft) Information Processing Unit,1617 MSIC,',Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 264- 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
(gpm) Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield m3 Method of test: air r
granulated chlorine /f o
13b.Disinfection type: Amount: L
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
1.