GW1--01396_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris Morgan I
14 iWATER;ZONES_'... :.,. 1 .
Well Contractor Name FROM TO DESCRIPTION
3572A
ibc ft. /46 ft. ( I
ft. ft.
NC Well Contractor Certification Number ,,.
A 1 •.15IbUTER'CASING(foriuulh•casednwells)'OR:LINER(if ap hcah ,°,le)�' .. .
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. \Os ft. 6 1/8 i in sdr-21 PVC
Company Name
�^ al ::16:INNER`CASINGORTUBING,(geothermal;closed.loop)t .?. , : ....
2.Well Construction Permit#: (/I 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.
11:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) INKtesidential Water Supply(single) ft. ft. in..
❑Industrial/Commercial ❑Residential Water Supply(shared) . • -
183:GROUT-.vu .0,. ... .,.,P�., .. _ '=, ..;. � ... .. i -,
❑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. I
❑Aquifer Recharge ❑Groundwater Remediation
19:'6ANDIGRXYELIP.ACK:(ifapplicatile) ..,, ` ..,<..., .' .,';,,..,
,;'
❑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 1DRILLINGLOOG(attach addrtional'sheeti if necessary),l ..) .
FROM _ TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) .
_❑Geothermal(Heating/Cooling Return) C❑`Other(explain under#21 Remarks) aft. (a R ft.
4.Date Well(s)Completed:2. 2-1 24 Well ID# (.4 f ft. SO ft' erOINK Sa eli,e-
5a.Well Location: 81 ft. 24S ft. art
&vs
t)a js 1JI •C/1 ft. ft. v►
Facility/Owner Name Facility ID#(if applicable) ft. ft.
t0f1/1 N P ehmj 10S T-Itt,S19Y4S 21 ZAZ ft. ft. II''--;I c_o i �k!E L _d
ft. ft.
Physical Address,City,and Zip
tAo6v� 11 A
21=REMARKS.. i ... ....,. .,.#.l, ';M Art...a'!.:;20Z4'. ,. , €
County Parcel Identification No.(PIN) 7 -��x
IntrUna:tV'1 i `.......'•�`"a -e
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I G 'r'f n OG
(if well field,one lat/long is sufficient) 22.Certification:
—may
35. 370e N [ 5127 W z,n,z(�
6.Is(are)the well(s): lPermanent or ❑Temporary Signature of Certi ed Well ContractorI Date l
By signing this form,I hereby cerdb,that she well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!No 15A NCAC 02C.0100 or 1SA 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:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CS- (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(4)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 2 0 (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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: a I r Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine Tie13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018