GW1--05754_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information:
II
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION I
Z75 ft zw, ft. I
3572-A ft. ft
NC Well Contractor Certification Number INC 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
MorganWell & Pump,m , I N C FROM TO DIAMETER. THICKNESS MATERIAL
p 0 ft. /1� in
ft- 61/8 • sdr-21 PVC
Company Name ``����
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2.023' loving FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,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 icipa]/Public ft ft. in.
ID Geothermal(Heating/Cooling Supply) 10esidential 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.
❑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 ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional'sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geotlermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
a ft. (40 ft. 2cc C 1a
4.Date Well(s)Completed: de 41-Z3 Well ID# 41 ft. "5 ft. eV.0
5a.Well Location: 1 Zb ft. ee ft r ��
pour Camas �L ft. J ft lJt 0�
Facility/Owner Name' Facility ID#(if applicable) ft. ft. )•
C C j 1� ,,.�A ..� r ^'^y
g 7 ssva >4-. D . lc-1�v'i Nic, ft. ft. 1 Imo. 4 lk �9
Physical Address,City,and Zip J ft, ft. i SEP 37Z41Z S541II 21.REMARKS 2023
County Parcel Identification No.(PIN) Inwrr"F'.rz‹.1 1 ?r.c-- ..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °QM '
(if well field,one lat/long is sufficient) 22.Ce •Ieatio :
35.-n 63 N Z.2641 w I
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certin,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l lNo ISA NCAC 02C.0100 or 1SA 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#2I 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).Ydu may also attach additional pages if necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 200'and 2@100')
rbO 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"+" i,
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: iC01'0.1L� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) J 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
Permit Program,1611 MSC,Raleigh
13a.Yield(gpm) 3 Method of test: a i r ',NC 27699-1611
,
granulated chlorine
13b.Disinfection type: Amount: 1201
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018