GW1--00883_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name ft. 06 ft.
3572A 5 ft. ft. I - --
NCWell Contractor Certification Number INC
CASING(for multi-cased'wells)OR LINER(if ap licable) .
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. SC) ft. 61//8 ; in. sdr-21 PVC
Company Name /
20� �� O�,}2 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: "i J 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 ❑� M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential 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 I 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DF RIPTION(color,hardness,soil/rock type grain size etc.)
t 6 ft. RU ft. eL cut
4.Date Well(s)Completed: 12//ZJZi( Well ID# (i ft. CTiI ft. 19) C 16.
5a.Well Location:
0 ft. 3q5 ft. /_ �4 z
Ck P ft. ft. vl,�J(
Facility/Ow�n/e�rNla,,me Li I /FFaacilityDM(ifappllicable) - ft. ft. _ ^
W(7t'loi . CogeQYJ !�� 41007 ft. ft. a�,R ,,»'k..,..:,i; ocf^.1-:-.....L,-r'
Physical Address,City,and Zip ft ft. r r ri 0 5 am
atheivivS 21.REMARKS
art,-, g l N
County Parcel Identification No.(PIN) 1R;JIi,ti=?�O+ wig lC=R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiftio :
35. LO ZDG Q/j N a v.5d ip W i'-15 Z,1y
6.Is(are)the well(s): I lPermanent or ❑Temporary Sig e of ertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 6No 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 I 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 I
9.Total well depth below land surface: 'VL (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 Ito Division of Water Resources (DWR),
10.Static water level below top of casing: 4/0 (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DV1R,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 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) 2. Method of test: air,/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount: `y�Z '
I '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018