GW1--05778_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I'
1.Well Contractor Information: I j
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3572-A '460 ft. Lit ft. {
D. fL I I
NC Well Contractor Certification Number
INC15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, N FROM TO DIAMETER THICKNESS MATERIAL
0 ft. YO ft' 61/8 in. sdr-21 PVC
Company Name
/J//yy /�/�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2023- Oo1ZO FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1 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 ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) X,R4idential Water Supply(single) fL 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
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer•Recharge ID 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.
❑Experimental Technology . ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
) ft. 1 ft. ig°rdWNl. 1.I Q
4.Date Well(s)Completed: S-24'Z5 Well ID# if ft. 7 io ft • �� 4-e
5a.Well Location: ,�/ ft.ft. ft. v1 Yt4l�
kilbe 1 •
A1ea(W ft. `,
Facility/Owner Name pp Facility IN(if applicable) ft. ft. l^ (a y t• F�'• ,;
t o 32.b ki 1ckor std Clz (14 I 4t1S to l Nv ft. ft. �.�L..
Physical Address,City,and 7p ft. ft. S E P a h 2023
/.lckV)�Ns 21.REMARKS
County Parcel Identification No.(PIN) Lfh�'ift Fia'at tip;
043
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C •lcati
,3.5"274( N go.Wei W _ , g,.3a a
6.Is(are)the well(s): l!Permanent or ❑Temporary Signa of Certified Well Contractor I Date
By signing this form,I hereby cer t(that the'well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It/No 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: 41 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
10.Static water level below top of casing: 0 24a. For All Wells: Original form to,Division of Water Resources (DWR),
(ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 1/8 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: %04ttr1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) it 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
air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test: l .
granulated chlorine �f
13b.Disinfection type: Amount: L 1 0L
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018