GW1--02195_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3572A II4gt. oft. 1
ft. ft. I '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased (wells)OR LINER(if ap licable)
Morgan Well & Pump, INC^'V C FROM TO DIAMETER , THICKNESS MATERIAL
0 ft. JZ ft• 61/8 • in• sdr-21 .PVC
Company Name
25 00�-E O 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 ❑MMu�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Cesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000GPD 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
DAquifer Test ❑Stormwater•Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothernal(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„rain size etc.)
ft. ?r,) ft. fi A
4.Date Well(s)Completed: 1 QL' Well ID# of ft. L., 4 ft. 19 MAil. J
l�c ft. 7� ft. ^radii /,►�/ /n(.pr
5a.Well Location: LL ) (J� J l�l�if� I,
j2pIcJ_ it ft. ft.
Facility//OwnerN`ame I �} Facility�l #n(ifrapplicable) (% ft. ft
J 1 o Y r W/V 1 � ,bill 2F1.3 O ft. ft. i 'E_ `... L. . V L--.
Physical Address,City,and Zip ft. ft. APR n p %n 74
IZ1oYIJt/
^ ,ME 21.REMARKS �f I
County Parcel Identification No.(PIN) In`" f C 1 'a -'r'y'v"n' �' 't
DWG.;30G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C r i ation:
3515 (DI I N - 70130 W ( 11/1J s
6.Is(are)the well(s): l lPermanent or ETemporary Signature of Certified ell Contractor t1h12
By signing this form,I hereby certfry that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ONo 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#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: 20O (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(41200'and 2@100')
n 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (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
i
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 V M
13b.Disinfection type. Amount: lI V /�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' I Revised 6-6-2018