GW1--01568_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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14.WATER ZONES' '
Well Contractor Name FROM TO DESCRIPTION
ft. ft. i
4CC G-- 0 ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. LI Q ft. 6 1/8 , in. sdr-21 PVC
Company Name
3S3 7'6.� .16.INNER CASING OR TUBING(geothermal closed-loop)' '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCWater Supply Well: FRO ICE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(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 ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft.
i ft.
❑Geothennal(Closed Loop) ❑Tracer ,20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
,}� it. Is ft. /f �;rt.
4.Date Well(s)Completed: �� Well ID# `t ft. J (Pit. `)3ia ) 1n,�,1- -^
LA ft. k 7 ft. f/r 'i!'tfCc ` �+ Ili. i ,(,R
Sa.Well Location: r cccJ/I�JJj
5LV%� SCAMP 3D ft. zy5 ft. /I4t/6jlT(4I_,C • v �..
Facility/Owner Name Facility ID#(if applicable) ft. `7 ft. MAR V p Z02rl
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2 1 ow JAo eP. fr,i. t 0 ft. ft. Hli`Cri14:s':n •��
ft. ft. r.... ..,`„,a:':�I
Physical Address,City,and Zip r�45 J(i
A „+ -e 21.REMARKS , _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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(if well field,one lat/long is sufficient) 22.Certificatio •
3c 7/, 41. N 'go. 0(cy__ W 1-3/-24
6.Is(are)the well(s): l lPermanent or ❑Temporary Signature of ified well Contractor Date
By signing this form,I hereby cerBfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A 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#2l 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: ��5 (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)
24a. For All Wells: Original form to Division of Water Resources (DWR),
_ ,10.Static water level below top of casing: 3b (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: rota r}/
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
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granulated chlorine l ` 0 ,
13b.Disinfection type: Amount: 111 �7 • ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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