GW1--02185_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: • I I
Chris Morgan •
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION I
3572A >l2s ft. 1,26 ft 1 1 •
ft. it. I 1 .
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 I THICKNESS MATERIAL
0 ft• 53 ft 61/8 in.i sdr-21 .PVC
Company Company Name O I I 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.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) residential Water Supply(single) ft ft. in.
❑lndushial/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
OMonitoring ❑Recovery ft. ft .
Injection Well: .
ft. ft.
❑Aquifer Recharge 0 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 0 Subsidence Control ft. ft. i
❑Geothermal(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,soillrock type,grain size,etc.)
1p 0 ft. ft. b a, !)
4.Date Well(s)Completed: ' \I2) 1 Well ID# /1 r• ft. 16 5 ft ( 1� '
C l 6tS Ut ;1Aalr►�
Sa Well Location: ft. ft.
;S 3 COW) IL( ft. ft. r“--, T 7. • .
Facility/Owner Name • Facility ID#(if applicable)
• 1"330 0°)Rel cvVU Dlr.- 5:1Ifs bur",Ai& ft. ft. APR o 8 2.0'1
Physical Address,City,and Zip /�/� r,�/� ft ft r ^n
1' D\N 6/l. 1.0 1 N )-4 21.REMARI{S ie t.. .. G , C. .11:'' : l l'
,rY evJ'..�Vts
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/ong is sufficient) A , 22.Cer• don:
%.ggZ.67 l l N qV Un 3 W -2.5-Zci
6.Is(are)the well(s): l'lPermanent or ❑Temporary Signature fCertified ell Contractor Date
• 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 I5A 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#2I 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:t 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: I VS _(ft.)
For multiple wells list all depths if different(example-3 rem 200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
•1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing•use"+" - i
1
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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,1000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: a j r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount: 715Z,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018