GW1--02156_Well Construction - GW1_20240408

I
WELL CONSTRUCTION RECORD(GW-1' For Internal Use Only:
1.Well Contractor Information: •
Chris Moran .
g 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION'
3572A 2po ft• 261 ft. 1?„�f'"^
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Morgan Well & Pump, l N C FROM TO DIAMETER I ; THICKNESS MATERIAL
0 ft. tO ft. 6 1/8 in.' sdr-21 PVC
Company Name -
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2_ .k,'3Z7• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well constriction 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 ❑M ipal/Public ft it. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft in.
❑Indushial/Commercial ❑Residential Water Supply(shared) 18.GRODT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. bentonite poured
OMonitoring ❑Recovery ft. ft. ,
Injection Well:
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rbck type,grain size,etc.)
O ft tis ft g,,d Cf.0
4.Date Well(s)Completed:?l'Z Well ID# L ft. I5 ft. 6tat,..,v.L. 0
5a.Well Location: Ltl6 ft. t]S ft. ginVit f` _e-
C n 11 1'WV 1 0' knckaQ L�'L ft. _l 5 ft. c �RUtWLC'SrYo
Facility///Oww/nerNaame 1 1 • Facility ID#(if applicable) v ft. ft.
• L i D vhdy Vint 2 l 0'Oe p,". kt ix, 5,11,{kL ft ft 71 _�
Physical Address,City,and Zip ft. ft. • o t'EL..:.i.,V h )
TV at Lk 1 (ib 6-1 Qdd,l 21.REMA UCS ,APR Os 2024
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: In"+if""`U? ^:,;W;,•,.a��r�'S
i_s b''`,I C,',./0(3
(if well field,one lat/long is sufficient) 22.Cer math)
,SyG2 N .`Ga 710 W it Z5-Zt(
6.Is(are)the well(s): EtIPermanent or OTemporary Signature of Certified Well ContractorI
Date
By signing this form,I hereby cent fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No ISA NCAC 02C.0100 or 154 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:124.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z23 (ft.)
For multiple wells lisi all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `0 (ft) Information Processing Unit,1617 MSC)Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 1/8 (m) 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) .2
- Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: /iZ
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018