GW1--06490_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: ,
Chris Morgan 14.WATER ZONES f
WellContractorName FROM TO DESCRIPTION
3572A 1,2,S ft• 13koft I '
ft. ft. 1 .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
Morgan Well & Pump, I N C FROM TO DIAMETER t THICKNESS MATERIAL
0 ft ft 61/8 in; sdr-21 PVC
Company Name
r 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 ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) iliesillential Water Supply(single) ft ft. in.
❑Industrial/Commercial • ❑Residential Water Supply(shared)" 18.GROUT
❑lirigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMET$OD&AMOUNT_
Non-Water Supply Well: 0 fr• 20 ft• bentonite poured
OMonitoring ❑Recovery ft. ft
Injection Well: •
ft. ft.
❑Aquifer•Recharge 0 Groundwater Remediation
❑A uifer Storage and RecoveryOSalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
q g FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft
DGeotherrnal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,h rdness,soillrock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed:1011�124 Well ID# 0 l ft. '11 ft b n{/111 %/1C(S311/U1.
5a.Well Location: �1'�ft 1 t ft q r Ins 4-
RTA'l ct, �����1J r ft. l AlL ft. V �',1/� �1 1 l�
Facility/OOwfneerName C • Facility]D#1(if applicable) ft ft.
' Soso � 1S26� )dt 1 V V 2. 1 R ft ft _
Physical Address,City,annWZip ft. ft. N U V �� t!U
ttSWQn 4E6 CA 2) 21.REMARKS K.. . ...
Ili`.,. ;� •
County Parcel Identification No.(PIN) •
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laat/l(lo �'J� ,p (�ong is sufficient) 22.Certification: (-1
6.Is(are)the well(s): IlPermanent or OTemporary Signature of Certified Well Co ctor Date
• By signing this form,I hereby milli,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15ANCAC 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 ofthis record has beenprovided fo the well owner.
repair under#2I remar.7 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:I 1^ 24.SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: 1 W S (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wills list all depths ifd�erent(example-3@200'and 2@100')
10.Static water level below top of casing: v
'.3 f) (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.Borehole diameter: 6 1/8 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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,directpnsh,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) 'XJ Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699,1611
granulated chlorine
13b.Disinfection type: Amount: ��
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018