GW1--06461_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: •
1.Well Contractor Information: I i
Chris Morgan 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3572A 11 0". Il l ft.
ft. ft. .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Morgan Well & Pump, I N C FROM TO DIAMETER TFIICKNESS MATERIAL
Company Name 0 ft ft 6r1/8 in. Sdr•-21 .PVC
C '�E)U �bD\kig 16.INNER CASING OR rUt3ING(geothermal closed-loop)
2.Well Construction Permit#: y�V t/'T vv o FROM • TO DIAMETER TErCESEESS ?AAT RIA
List all applicable well construction permits(le.WC,Como),Stale,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft it in.
Water Supply Well: 17.SCREEN
❑Agricultural ❑M//unicipaUPublic FROM ft. TO ft. DIAMETER SLOT SIZE TRIMNESS MATERIAL
in.
❑Geothermal(Heating/Cooling Supply) litI sidential Water Supply(single) •
ft ft in.
❑Industrial/Commercial • ❑Residential Water Supply(shared) 1s.GROUT
❑hligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEIViENT=TROD&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) f
DAquifer Storage and Recovery ❑Sal in ity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
DExperimental Technology ❑Subsidence Control ft It. •
❑Geothermal(Closed Loop) OTracer 20.DBIE.IJNGLOG(attach additional sheets ifnecessary)
❑Geothermalfl
(Heating/Cooling Return) 0Other(explainunder#21Remarks) FROM ft TO ft I�rtDFSr IPTTON(color,hardness,sotllrocktype grain size etc.)
�o\al ��Well ID# S yl
4.Date Well(s)Completed. 1 10ft. '�sft 9 , r g �V
5a.WellLocation: ft
ft. It.
Facility/Owner Name - • Facility ID#(if applicable) ft. It. j:• ' i _> i t a
• 10 210 cm-o C►vt ell ft. ft.
Physical Address,City,anndZip ft ft �t�lt� C1 ��2�
CA106 ltk 21.REMARKS II.. - 1.-r :.'+•.':.i'"v
`i,� ��mro T...
County Parcel IdentiftcationNo.(PIN) O_fri•c'` lly
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification: •
S 4 S7 N - ' 3') W . •
d 2
6.Is(are)the well(s): nermanent or ❑Temporary Signature of Certified Well Contra of Date
By signing this form,I hereby cer iffy at the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!lNo ISANCGAC 02C.0100 or 151 NCdC 02C.0200 Well Construction Standards and that a copy
gads is a repair,fill Dui known well construction information and explain the nature ofthe of/his record has been provided to the well owner.
repair under#21 renwrls section or on the bar:of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed--hoop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1.-1
For multiple wills list all depths ifdifjerent(example-3@200'and 2Qa 100� (ft,) Submit this GW-1 within 30 days of complefion per the following:
10.Static water level below top of casing: ' (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use'+" Information Processing Unit,1617 MSC,Raleigli,!NC 27699-1617
11.BorehoIe diameter: 6 1/8 an) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
rotaryProgram,1636 MSC,Raleigh,NC 27699-1636;
12.Well construction method: I: •
12.Well
auger,rotary,cable, t push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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.YieId(gpm) too Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
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granulated chlorine Q-on
13b.Disinfection type: Amount: CI.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018