GW1--06445_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only: •
1.Well Contractor Information: • •
Chris Morgan 14.WATER ZONES I I
Well Contractor Name FROM TO DESCRIPTION I i
3572A ft. l5Akpft.
ft. ft. t 1
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NC Well Contractor Certification Number 15.OTITER CASING(for multi-cased wells)'ORLINER(if a licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. I '0 ft' 6 1/8 in•,' sdr-21 .PVC
Company Name n 16.INNER C ING OR TWANG(geothermal closed-loop)
2.Well Construction Permit#: 35\ V(,t r L} 4--s 71 2. FROM TO DIAMETER THtCKNESS M,4TERTAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE - THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
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0 Geothermal(Heating/Cooling Supply) 011eesidential Water Supply(single) ft ft. in -
❑lndustrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN,T.• ,''""'Th
Non-Water Supply Well: 0 ft. 20 ft, bentonite poured s \•' `'`='1.•x 2, 'A `+_.,L.)
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. f JO V ' J��
❑Aquifer Recharge 0 Groundwater Remediation r. •_,,r". •• ?,. ,•,
19.SAND/GRAVEL PACK(if applicable) �,'; t'cc,
❑A uifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT MErTHOR,'.if'-r Li
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTIO (color hardness,soil/rock
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) © ft. to ft
rn'�grainsizeete)
4.Date Well(s)Completed: \O\1 \ 'fWeU ID# '�ft. '^S ft çd :c
5a.Well ocation111nftOw cn ^ ;I
\(\ S�v��SI�Y1 `W06 ft. !L�„Lg11 ft .�til.�iV ``
Faciilty/OwnerName • Facility ID#(if applicable)
� ft. am)
ft.
• 15 l I Y'30\\e �lt2 O t i s ft. ft.
Physical Address,Ci ndZip l c ft ft.
r qigi�ZS�27 3 21.REMARKS ,
County Parcel Identification No.(PIN) .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.C tification:
S I V) ti I N N --'8 1) i$ 3-7a W
te at-[
6.Is(are)the well(s): l lPermanent or ❑Temporary Signature o Certified Well C, r Date
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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 I lNo 15A NCAC 02C.0100 or 15.4 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 ofthe 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 baying 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.
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drilled:124.SUBMITTAL INSTRUCTIONS
9.Total well depth below land.surface: '50 O (ft.)
For multiple wills list all depths ifdii different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ievel below top of casing:
O (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.BorehoIe 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 '
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air Permit Program,1611 MSC,Raleigh,NC 2769971611
granulated chlorine 15 b2
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018