GW1--01353_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
. Gv.y 1388 .1`4.WATER ZONES' .' . F..'
Well Contractor game FROM TO DESCRIPTION
5 . A ft. ft. I
ft. ft. I '
NC Well Contractor Certification Number •-15.OUTER CASING(for multi-cased vells)'OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. q ft, 61/8 i in. sdr-21 PVC
Company Name
I'/I�- 16.INNER'CASING OR TUBING(geothermal closed-loop);',
2.Well Construction Permit#: /L1✓cZ 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: Y7:SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.;
❑Geothennal(Heating/Cooling Supply) `Residential 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.
❑Geothennal(Closed Loop) OTracer • 20.DRIIJTNG LOG(attach additional sheets if necessary) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc)
7 � ft. /f3 ft. /l/Ok✓1 ,,/vt
4.Date Well(s)Completed: [� ��Z�J Well ID# 3 ft. 0 ft. /5 �f'd�i `
r Ct? /� /�,f'
5a.Well
/Location:
Mf�j� f�4 ft. ft. �/�e 1/2.,c:,6,/�
T / '✓ - co ft. lei5 ft. (i e `j�I C��;AZ
Facility/Owner Name ^ Facility ID#(if applicable)
ft. ft.
lZ 1 h!Nd/n ft. ft. •
Physical Address,City,and Zip
:
ft. ft.
G �' 21 R>MARKS
County Parcel Identification No.(PIN) ! ` i--•{ lr •)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MACS)I( 0 4 2024
(if well field,one lat/long is sufficient) �( 22.Certifica i..• U `t
S ..yei3�1 N [J �. 1�‘,; /�J W /, • fif rma4ivn iPrn,::.+ n;e ''Z it
mamoG
6.Is(are)the well(s): l lPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cent that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 1SA NCAC 02C.0100 or ISA 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:' I
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: gqs (ft.) Submit this GW-1 within 30 days of well completion per the following:
if For multiple wells list all depths different(example-3@200'and 2@100')
10 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') 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 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)_ 3 Method of test: a i r
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: granulated chlorine IAmount: 1.... g 01-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j . Revised 6-6-2018