GW1--04808_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 14.WATERZONES
Well Cont actor Name FROM TO DESCRIPTION
3572A 350 ft• as I ft
ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERLII.
0 ft. )31. it 61/8 in. sdr-21 PVC
Company Name tY
�J� ((���/�c 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ` 2-'&. O 00 S V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lnigation ❑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 ❑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 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) CD ft. 4 ft ll.�,ClJ� �
7
.'\
4.Date Well(s)Completed:��!_l�4. Well IDmil4 t ft. I q0 ft. l
R p�, C
5a.Well Location: 9/ ft l u ft ef'Wrl t 's estle
StOVelOtathatCOnc IS ft fits ft. G,r Gt
Facility/OwnerGy/ Name nl r_ Facility ID#(if applicable) ft. ft.
Zai J s�ko F-�' `-71'lCbVk l- ft ft - . )
Physical Address,City,and Zip t ft ft + `4,.... ` 4,... I )
Rew4n 2LREMARKS AUG 1 = 2024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D-/;;;,.;,r-�
(if well field,one llat/long is sufficient) � 22.Ce cation:
)51gcs9 ( ILP' !N --ViS ( W 7'etf
6.Is(are)the well(s): CJPermanent or ❑Temporary Signa of Ce red ell Contractor Date
By signing this form,I hereby cer•tin,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I,No 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 fonn.
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 OW-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: 2 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4120 'and 2@100')
0 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"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 1/8 (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
(ie.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) Method of test:
a I r Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: ) d?i•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018