GW1--06503_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only: i .
1.Well Contractor Information:
Chris Morgan 14.WATER ZONES I
Well Contractor Name FROM: TO DESCRIPTION I
3572A f`' `LStP ft
NC Well Contractor Certification Number ft ft I
15.0 U'1•L+R CASING(for multi-cased wells)OR LINER(if ap linable)
Morgan Well & Pump, INC FROM TO DIAMETER csN MATERIAL
A ,
Company Name 0 fft12� ft 6r1/8 in• I 'rmSdC 21 PVC
(� W?�.�]NN^Z� ��� 16.INNER CASING OR TUBING(geothermal dosed-loopl
2.Well Construction Permit#: 0 [[ FROM • TO DIAMETER. TBICENESS 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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1161r(sidential Water Supply(single) ft ft. in •
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Isigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft bentonite poured - �• ;,,.. ;.y
❑Monitoring ❑Recovery ft. ft c,,,a ,
Injection Well: 4',In9n 2024
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Sal inityBarrier FROlifSA D/GRAO LPACK(rfapplicable) Ir,`7.-. -^nf^
MATERIAL EMPLANEENTMETHOD.,_ : •``,- °„J••••
❑Aquifer Test ❑Stormwater Drainage ft. ft .is 4.1
❑Experimental Technology ❑Subsidence Control ft ft
DGeothermal(Closed Loop) ❑Tracer 20.DRUMS/GT.0G(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetur) ❑Other(explain under#21Remarks) F 10
ft TO ft. DESCR7PT10N(color,hardness,soillrocktype grain TO
4.Date Well(s)Completed:10 I`S 12-14 Well ID# (q I ft. ft I r ,�
fAi
5a.Well Location: %/„l ft j ID ft `r�/rin W An` C p
iki
Aid aalmss() �"V\ ft. �y1d� ft uYv� J
Facilittyy/OOwnerName • FacilitylD#(if applicable) {'V ft. l�J U ft. Ira/
• ;
J V �a WI/ + I�.r/' ft. ft.
Physical Addr�andZip 1I I ft ft. '
-1',sU_Zq_ 7 7 p1 2L REMARKS
L t3' Parcel Identification No.(PIN), •
`/T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/longis sufficient) 22.Ce tion:
35 (5Z035 N -gb 173 C163 W .
I0131 /21
6.Is(are)the well(s): 1hPermanent or OTemporary Signature of Certified Well Contract r Date
By signing this form,!hereby certify that the wells)was(were)constructed in accordancewith
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Conshuction Standards and that a copy
If this is a repair,fill out blown well construction information and explain the nature of the ofthis record has beecs pro sided to the well owner.
repair under#21 remarin section or ms the back ofthisfonm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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:+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z s GW-1 within 30 days ys of well completionper the following:
Submit thi p
For multiplengple wills list all depths if different(Example-3@200'qi2lUo)
10.Static water level below top of casing: ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If waterlevel is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 1/8 Cm.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(!ITC)
Program,1636 MSC,Raleigh,NC 27699-1636 I
•12.Well construction method: rotary
(i.e.auger,rotary,cable,direct 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 GI'D: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air Permit Program,16.11 MSC,Raleigh,NC 27699-1611 '
granulated chlorine
13b.Disinfection type: Amount: [ C -1,...
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018