GW1--06508_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-I) For Inteimal Use Only: '
1.Well Contractor Information: •
Chris Morgan 14.WATER.ZONES j
We1lContmctorName FROM TO DESCRIPTLON I
3572A /al) ft eLF1 ft.
„j os ft. %left 1
NC Well Contractor Certification Number 1 .OUTER C G(for multi-cased wells)OR LINER(if a linable)
Morgan Well & Pump, INC PROM To DIAMETER THtcarNESS MATERIAL
0 ft. ft 61/8 hi- sdr-21 .PVC
Company Name
(
Ip /V 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it:UN v�'1 's to I PROM To DIAMETER TrCKNESS MATERIAL -
List all applicable well conslructionpersnrs(Le.UIC,County,State,Yariance,etc.) ft ft. in.
3.Well Use(check well use): it. it. in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipa1(Public ft. ft. in.
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❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustriallCommercial • ❑Residential Water Supply(shared) 18.GROUT
❑Inigation ❑Wells>100,000 GPD Mom To MATERIAL EMPLACEMENTMETHOD&AMOUNT-,
Non-Water Supply Well: Q ft. 20 ft, bentonite poured { �'' R,,a Fl. ''i jr. s
❑Monitoring ❑Recovery ft. it •' 4...:, i
Injection Well: ft. ft. NO V 0 1 2024
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) h ,.S.t- .3
❑Aquifer Storage and Recovery ❑SalinityBairier FROM TO MATERIAL EMPLACEMENT METHOD;:,- ,..: '" I Ui
OAquifer Test ❑Stormwater Drainage ft. ft -• I V
❑Experimental Technology ❑Subsidence Control ft. ft '
❑Geothermal(Closed Loop) • ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION'/ (coign,h /ess,soil/rock type grain size,etc.)
{� ( (, ft `u ft. f Q G C �I�✓w/
4.Date Well(s)Completed:A 0`l VI2 f Well ID# VV�0 ft. 4 ft byr ,t ,i^ 7,
I U-Y�' t �
ta-e.
csadusiwri5a WeIlLocation: j1�jJ/� f 0 /H it �t /, 3t4IAf1k.IIIel 1. c lLi ft.
Facility/OwnerName • Facility ID#(if applicable) ft. ft. '• r
• 122 Qua 1 a t C-botnvt(it
ft , ft .
Physical Adrress, ' and Zip it ft.
,IY 'I u I 3r,70, 21.REMARKS - •
County Parcel Identification No.(PIN) . 1 .
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Sb.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one 1st/
long
giis sufficient) 22.Certi6
Cl O
S• 1 -1 N - roc t 9g Wiolgrilaii
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
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By signing thisfotm,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or InNo 154 NCRC 02C.0100 or 151 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill our known well construction information and explain the nature of the 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 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.
• ed'' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '4 4 0 (ft.) •
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
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24a. For All Wells: Original form-to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 1/8 (m.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,"NC 27699-1636
12.Well construction method: rota
rY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(1.e.auger,rotary,cable,directpush,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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) '2 1Vlethodoftest: airI
granulated chlorine //
13b.Disinfection type: Amount: f 7 0 7
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018