GW1--01357_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) "For Internal Use Only:
1.Well Contractor Information:
3 /
a '0dc414 ',14:•WATER ZONES' ±,
Well Contractor Name FROM TO DESCRIPTION
CY656-4 ft. ft.
ft. ft.
NC Well Contractor Certification Number INC
CASING'(for multi-casediv'ells)OR LINER ap licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
_ 0 ft• kig ft• 61/8 i. in• sdr-21 PVC
Company Name
16:;INNER•CASING OR TUBING(geotherinal'closed-loop) -2.Well Construction Permit#: /7�CJ� 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) Vt5Resideptial 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 ❑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/Cooling Return) ❑Other(explain under#21 Remarks) ft. �J/n ft. iJ��.f 1 .
1-31-a o (�' cif
4.Date Well(s)Completed: Well ID# J�(,0 ft. ',1 ft. 8( „i Of.J/ .
5a.Well Location: • iiirS ft. 7 C!�/�/ ft. /417
frIv,.t �f
141ye $
7 11 cifl �ft. � ft. uco/�/�L •
Facility/Owner Name Facility ID#(if applicable) // ft. ft.
13 V ,ehe/ 6441% !`-til ft. ft.
Physical Address,
City,and Zip ft. ft.
CZt:ZS'S�ben 21.iREMARKS' x,m
County Parcel Identification No.(PIN) w .^ ,.
D5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: MA N O 4 •
c S36 Zss !J3 N it' °g�67 W Zoz4 _r! L�/J
Signature of" Certified Well Contractor r ate
6.Is(are)the well(s): L'1Permanent or ❑Temporary gt' C�fiCui7G
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 PJNo ISA 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-I 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 •
9.Total well depth below-land surface: �� (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'
10.Staticwater.level below top of casing: Syl7 24a. For All Wells: Original form to Division of Water Resources (DWR),
(114 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
t t
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) •
11.Borehole diameter: (in.) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I c Method of test: air
g 0�
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 6-6-2018