GW1--07744_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information: ;
Chris Morgan 14.WATER ZONES I
We1lContractor Narne FROM TO DESCRIPTION
3572A V ft.ft.aatoft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.licable)
Moran Well & Pump, I N C FROM TO DIAMETER. THICKNESS MATERIAL
companyame 0 ft' ft. 6 1/8 i in' sdr-21 PVC
� � - oO �o�� 16.INNER CAS GOR TUBING(geothermal closed-loop)�
W
2.Well Construction Permit#: 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.
17.SC
Water Supply Well: FROM REE TO _ DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) esidential 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 OSalinity 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)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) O ft ' O it I J nU 1 C
ia4Atrusmu,
4.Date Well(s)Completed: •I I a 3 Well ID# 1 ft. LO ft. �M`
5a.Well Location: ' ft. 04 le ft. r Aile vt
ft. ft.
'' 11 ft. ft. E a L '+- _ ' )
-'
Facility/OwnerNameFacilityID# if applicable) a 2,-. A..,_r 1, _
V)Sll t V S tAtapikkdrkb,srbft
ft. ft. �rC J 2023
Ph sical Addr ss,C}IIZip J J 21.REMARKS
County Parcel Identification No.(PIN) l'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. 'fication: 1
•3l (p - ► coD N -1C1,, 161 col W (aI,/?..3
6.Is(are)the well(s): CJPermanent or ['TemporarySignature of Certified Well Contract Date
• By signing this form,I hereby certify tat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 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 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: -1 (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(4)100)
2 0 24a. For All Wells: Original form' to Division of Water Resources (DWR),
10.Static water level below top of casing: J (11) Information Processing Unit,1617 MSC,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: 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 department of the county where installed-
t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) S Method of test: a i r
Permit Program,1611 MSC,Raleigh,INC 27699-1611
granulated chlorine �7
13b.Disinfection type: Amount: 0 L
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018