GW1--01334_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Chris Morgan _
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION i
3572A 2,0 ft, 2(( ft. 1
ft. ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. sg ft. 61/8 .111• sdr-21 PVC
Company Name
`1,,1�t„1/�� I_py. �^^/�� 1 �� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#. •1 1 J '1 (t()L GDD 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 cipal/Public ft. ft. in. •
OGeothermal(Heating/Cooling Supply) tW esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lnigation ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 • ft 20 ft bentonite poured
OMonitoring ❑Recovery ft. it
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater•Remediation -
19.SAND/GRAVEL PACK(if applicable)
DAquifer 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)
FROM TO DESCRIPTION(•lor,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 20 ft.
4.Date Well(s)Completed: ,1013I 123 Well ID# 31 ft. W ft b,/-1n t/� 5` e S]jyn0
5a.Well Location: Sl ft. 2� ft. 99�v�7� an., .. U►'
��ni- �(\ ft. (J ft. J
Facility/1OwneerName � 1 l �J(1/�/Fac�ility�ID#f(iifapppplllicable)( ft. ft.
�1`�V, le,94 W t tw 1 t/l l� 2J ft. ft , .71 i E� y A l}Vt�.�P/h�sical Address, and Zip ft. ft p i
l•/l�`,M S 21.REMARKS IViAK 0 A 2074
County N•t UV Parcel Identification No.(PIN) }'^n c 11PIN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D°1a/7:OC
(if well field,one 1at/long is'sufficient) 22.Certification:
s,5110\1 N �n. ?D 3 W i 11 I 03
6.Is(are)the well(s): OPermanent or OTemporary
Signature ofCertifie. 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: DYes or l lNo ISA 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:r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: --40 (ft '
For multiple wells list all depths ijdi�erent(example-3Q200'and 2@100� ) Submit this GW-1 within 30 days of well completion per the following:
!�
10.Static water level below top of casing: (ft.0 ) 24a. For All Wells: Original fonn to Division of Water Resources (DWR),
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 to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 7699-1636
�1/
12.Well construction method: rota'J 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
i air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test: / I
granulated chlorine f/t 0 f�
13b.Disinfection type: Amount: "1 /-
•
Form GW-1 0 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 6-6-2018