GW1--03418_Well Construction - GW1_20240610

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 140 ft 361 ft
ft. ft
NC Well Contractor Certification Number INC 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• it el ft 61/8 in. sdr-21 PVC
Company Name -
-. �� -v r.,t.. .-- met r,
List all livable well construction permitsa as
you tru�4uu�eiuuL � -. "'tc°�- �
applicable (i.e.WC,County,State,Yartance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in. -
17.SCREEN
Water Supply Well:
!Mg=� SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muricipa]/Public ft.
•
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ['Residential Water Supply(shared) 18.GROUT
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EM PLACEMENT METEOD&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 ❑Stormwater Drainage ft. ft
❑Experimental Technology ['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,hardn ,. soil/rock p e,:rain • etc.
- 4 ft. ZS rt. ;A.,'6"4„Lcl
4.Date Well(s)Completed: 513 L�•l Well ID# 2� ft. 4,00 ft /± 1 �t
5a.Well Location: ft. ft. C7►
kailn Clarke ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft '-%...`, . .. -:': . 7
12Z6 MA. /Aim- N. .kd k-1t.\oNC ft ft. 1
Physical Address,City,and Zip ft. ft. 1 87
CalJ ousts 21.REMARKS liii
County � Parcel Identification No.(PIN) Ott4+404
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
SS r 4 g-1 P N - Y0 4 3'13 09 W ( -/Il
5/S-Zy
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or Lid NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown 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.
ed'drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 00 (ft)
For multiple wills list all depths if different(example-3@200'and 2Q1000 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: 30 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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: rota ry
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) �i Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
air
granulated chlorine It'
CZ
13b.Disinfection type: Amount: G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018