GW1--06507_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i •
1.Well Contractor Information:
Chris Morgan .
• 14.WATER ZONES I
WellContiactorName FROM TO DESCRIPTION
'ram ft
3572A '�' ft. ft. i .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a llcable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft 1 it 61/8 in' sdr-21 PVC
Company Name /� 16.INNER C 511IG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3'21-1 `0 l 1 FROM TO DIAMETER _ THICKNESS MATERIAL
List all applicable well construction permits(i.e.LlIC,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
DAgricultural ❑Municipal/Public ft ft. in.
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❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑lndustrial/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 I°- ,•. = ' o -
OMonitoring DRecovery ft. ft. NOVInjection Well: ft. ft. O t) I 2024
DAquifer Recharge 0 Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable) :.Y 4 #
DAquifer Storage and Recovery ❑Salin ity Barrier FROM TO MATERIAL EMErJICEMENT.METTHOD ....'
DAquifer Test ❑StormwaterDrainage ft. ft l r,'•�-,..
❑Experimental Technology ❑Subsidence Control ft. ft. .
OGeothennal(Closed Loop) • ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size eta)
o ft. 1 {0 ft. e
tk
4.Date Well(s)Completed: 1 0 t t4(24 Well ID# Li l ft. 6 5 ft b L
Sa.Well Location: +//� I��ft. l r ft /_nj, N
��l,lU1 VlA L�ft. •510�GGft. 9'4'9
U f'U '9tn.M..14?
Facility/OwnerName FacilityID#(if applicable) ft. ft. •
• 0 1-1 Gar U• 1 1-tu U•, 1 t t(o r C•StA l L., ft ft.
Physical Address, •ty and Zip ft ft
qI nS-2, --t1p-tc 21.REMARKS .
County Parcel Identification No.(PIN) •
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient)(rJrJl �� W 22.Certification:
7 S 1 N _ � i (%�k 1o131I a
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified W Contra or Date
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By sig»tug this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or EnNo 15ANCAC 02C.0100 or 151 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 remark.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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary•
• drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 2ta0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd jerent(example-3@200'and 2@100')
tA. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: O (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: 6 1/8/8 (i) 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 •
e
FOR WATER SUPPLY WELLS ONLY:
(� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) libk U� Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
granulated chlorine 0 /v 2)
13b.Disinfection type: Amount: ( Cr •
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018