GW1--02189_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
Chris Morgan 14.WATERZONES 1
Well Contractor Name FROM TO DESCRIPTION
3572A Ito ft. IL ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, l N C FROM TO DIAMETER i THICKNESS MATERIAL
0 ft. q O ft. 6 1/8 in.; sdr-21 PVC
Company Name
��I 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(JIC,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' OM3nicipalfPublic ft. , ft. in.
OGeothermal(Heating/Cooling Supply) Vfesidential Water Supply(single) ft. ft. in.
❑Industial/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 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.
❑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,soil/rock type,grain size,etc.)
©. ft. CI6 ft. 4d C/
4.Date Well(s)Completed:3 1-1\ Well ED# elf ft. LC ft. C5a.Well Location: f 16ft. gt�� fttrat4/1_,,,s‘t
` �''4VV��
CanQr GW►'tzarG 1 1--- g ft. re- ft (/lFf�/j Gckarit e
Facility/OwnerL/O Name J/ ,, / • Facility ID#(if applicable) p(/ ft ft f
1 F bib 4,1(r\ l.E'il.l 1-w\ Rd.. Scilis J t J Vt, ft. ft. " t'3--- ‘,,,+9..,i r' kir. i. ,
Physical( Address,City,and Zip ` go
) ft. ft APR
❑ j,7
ov Ckn V��lJOI� 21.REMARKS li f, v LU��
County Parcel Identification No.(PIN) `- -L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G /C:i
(dwell field,one lat/long is sufficient) 22.Certificatio
5.6?75 N ,`4,377d W
6.Is(are)the well(s): lSPermanent or ❑Temporary Sign a of erti ed Well Contractor Date
By signing this form,I hereby certiP that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l lNo 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 remarls 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
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9.Total well depth below land surface: I D S (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: i 6 (ft) Information Processing Unit,1617 MSC,i Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: 6 1/8 (i) 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
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13a.Yield(gpm) !�nn Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: -16Z/
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018