GW1--00882_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES I i
FROM TO DESCRIPTION
Well Contractor Name
3572A 356 ft. 3S 1 ft.
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
0 ft. 0..' ft' 61/8 ' in' sdr-21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 26 Z O a t5 b 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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) li sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
❑krigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 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) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) I
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Coolingg Return) ❑Other(explain under#21 Remarks) 0 ft. Uw it. 1Q_ ( /j�
4.Date Well(s)Completed: �/31Z Well ID# 1 .1 ft. SZ`U it' igfenW 1�. 5a�,d
! S'�i
7✓ll°
5a.Well Location: ,>/(2 ft. 326 ft. /1-f, /d am r�p
`�rearl jebi4 ft. ft. VSr"`J` v� -_
Facility/Owner Name Facility ID#(if applicable) tt, ft. e^.a C....5 . , ' .' )
C'HO CO II r ,s EA• ( It ov ,'' ft. ft. �. r
Physical Address,City,and Zip ft. ft. r CD J [U2
4
Ca ,ly s 21.REMARKS - " t r,.
County Parcel Identification No.(PIN) DWt,l:r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• (if well field,one lat/long is sufficient) b 22.Certi ation' I
35.(111 2I N DO.521Z W 1&ilzti
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature of Celli ell Conuactor Date
By signing this form,I hereby certifii that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 1SA 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 1121 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-I is needed. Indicate TOTAL NUMBER of wells
drilled:r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 v (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diferent(example-3@200'and 2@100') 1
d (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"+"
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
12.Well construction method: rotary 1
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
13a.Yield(gpm) S Method of test: air -
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount: 160z. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018