GW1--07643_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan ,,14.WATER ZONES o r, _.:.
WeIlContractor Name FROM TO DESCRIPTION
3572A lko°ft.4.k!0 ( ft.
ft. ft.
NC Well Contractor Certification Number
^'
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. (4oZ ft. 61/8I in' sdr-21 PVC
Company Name
p�O t� ,16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I 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•r SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) rairgidential 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 ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)` -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION,hardness,soil/rock type,grain size,etc.)
110 ft. ao ft. r CLOP-
of4.Date Well(s)Completed: \`\ �� Well ID# .Q C ft. to ft.
(n O ft. ft. �� Ctii -
/Well Location: ' r._ `� 1�,�I j (D c. /,
�Q. `Q ,sft. 11 --
cft. �l V cot . '
Facill�wner Name - Facility ID#(if applicable) ft. ft U
1031 Oall.2(Qa Sanvtr ft. ft.
Physical Address,City,and Zip ft. ft.
C�a� '21.REMARKS :
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D!I C a '- 2023
(if well field,one lat./long is sufficient) • 22.Certification: '
•3S, 2'113-ko N YO .1,5ZZ7/ W , in`:,+x. ;Q, $ f.: 1jr,i
Ia) a�
6.Is(are)the well(s): InPermanent or ❑Temporary
Signature of Certi t ell Contractor Date
By signing this form,I hereby certiA)that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: El Yes or I No 15A NCAC 02C.0100 or 15A 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 dwell 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-LoopGeothermal Wells having the same You may use the back of this page to provide additional well construction info
p (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:, 24.SUBMITTAL INSTRUCTIONS
c/
9.Total well depth below land surface: 1 b (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 to Division of Water Resources (DWR),
10.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 1/8 (in.) 24b.For Injection Wells: Copy Ito'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 depaitrhent of the county where installed
FOR WATER SUPPLY WELLS ONLY: I I
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) 1 U Q Method of test: air I
granulated chlorine
13b.Disinfection type: Amount: -1 02-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018