GW1--01395_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3572A . `sp ft. /Sr ft. 1
ft. ft. 1 j
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedswells)OR LINER(if ap licable)
Morgan Well & Pump, I N C FROM TO ' DIAMETER' THICKNESS MATERIAL
0 ft. 'IOS ft• 6 1/8 I in. sdr-21 PVC
. Company Name
^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Ul U FROM TO DIAMETER, THICKNESS MATERIAL .
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft ft. in.• .
❑Geothermal(Heating/Cooling Supply) UZsidential Water Supply(single) ft ft. in.
0 Indust ial/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 DRecovery ft. ' ft.
Injection Well:
ft. ft. ,
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
'
DExperimental Technology ❑Subsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) E Other(explain under#21 Remarks) FROM •
TO DESCRIPTION(color,hardness,soil/ruck type,grain size,etc.)
a1 rip a� Q ft. yO ft te� C'e
4.Date Well(s)Completed:"' 9. lt^ Well m# J ft. g< ft. � Jar`
jff,eta-
5a.Well Location: 6 ft. , ✓< ft. Cvt /„
t y 1(I ft. ✓ ft. , J V`
�J y ft. ft.
Facility/Owne ame • Facility ID#(if applicable) _ � _
1 r G Rws...
spting
Physical Address,City,and Zip A4 IN L OW j 1 0 s Ll J l ft. ft. MAR
n\QU 6 21.REMARKS
2021
S.;
County Vv Parcel Identification No.(PIN) - , 'Jr"-^•ti' 2 VF+�
It Mvi...^vf,^7 .
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: WG.' 1
(if well field,one lat/long is sufficient) 22.Cer• ation: J
35. 37Sa N 71% STy6 w zq..g.tl
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified ell Contractor 1 Date
By signing this form,'hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 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 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:' Q�e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V J (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 c@200'and 2 a@100)
Z a (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing-use"-I" (. '
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) 1�• Method of test: air
granulated chlorine Q�
13b.Disinfection type: Amount: VQZ
Form GW-1. North Carolina Department.of Environmental Quality-Division of Water Resources Revised 6-6-2018