HomeMy WebLinkAboutGW1--00884_Well Construction - GW1_20240205 I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information: I
Chris Morgan 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTIONI
3572A 3((p ft. 341 ft. 1
-
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
• Morgan Well & Pump, INC^'V C FROM TO DIAMETER. THICKNESS MATERIAL •
0 ft. 7g ft. 61/8 in. sdr-21 PVC
Company Name
wAn 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit it: [�[.Y�J: - d 0e3 56 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. lin.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: • 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipai/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>100,000GPD 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)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
p ft. to
ft. cw+�t Cla�
4.Date Well(s)Completed: iZ lO�L3 Well IN IV ft. 7 0 ft. w� S -__r
5a.Well Location: 7) ft. 346
ft. y a� t .
Trowis Cost ft. ft. (J►
Facility/Owner Name
Facility ID#(if applicable) ft. ft.
,it`is R,,-CLO1Q. aute,h124 . Cdile0cdI,e- ft. -ft. _ r y
'1'''-'r"-,
Physical Address,City,and Zip ft. ft. _ .t'-- �'1(1,. i. @ Y 4'•;« '
/� 6M 21.REMARKS
(,ta, Lb 5 L024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -'i-.-I irr•-• L.-F'"'lit a t
10.i V'1/f�i�'.:...
(if well field,one lat/long is sufficient) 22.Certifcatio : I D v :J=%Ow
35rLitn 1 N 90.6q ill w I l l I S1Zq
•
6.Is(are)the well(s): (!Permanent or ❑Temporary Signature of Certified 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 !No 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#21 remarin 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:I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3615 (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')
�d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10..Static water level below top of casing: 'L )
(ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 6 1/8/8 (in.) 24b.For Injection Wells:Copy to 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 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) IS. Method of test: a i r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
granulated chlorine
13b.Disinfection type: _ Amount: / 'onj- ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018