GW1--06509_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information: • •
Chris Morgan •
14.WATER ZONES I
WellContactorName FROM TO DESCRIPTION I I
3572A ?' 3ft.
ft. ���```'''111 ft I
Na •
Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINE,R(if a licable)_
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft 11 ( ft 6 1/8 in. sdr-21 .PVC
Company Name
r► i,, 16.INNER C G OR TUBING(geothermal closed-loop)
CS
2.Well Construction Permit#: (NZ it W( �� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits(l.e. C,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 is. ft. in.
•
OGeothermal(Heating/Cooling Supply) l idential Water Supply(single) ft ft in. -
❑Industrial/Commercial • ❑Residential Water Supply(shared)' 18 GROUT
Dilatation ❑Wells>100,000 GPD FROM TO MATERIAL _EMPLACEMENZMETHOD&:AMOUNT ---.-1
Non-Water Supply Well: 6 ft. 20 ft• bentonite poured -'�R:.��:.,; :y,, '1 ;•_,L _)
❑Monitoring ❑Recovery ft. ft Injection Well: N ON 1 7324
ft. ft
DAquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Sa]in i Barrier 19.SAND/GRAVEL PACK(if applicable) lr,`:,;;^,_i. i'-n';v,,1' t„W t
q g tY FROM TO MATERIAL EMPLACEMENT MIrTHOD.. 'U
❑Aquifer Test ❑Stormwater Drainage ft ft
[Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.)IR]ILING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21.Remarks) FROM T DESCRIPTION(co r,bar ess,soillrack type,grain size,etc.)
0 ft. C O ft. fie d a
4.Date Well(s)Completed: (0 I 101254 Well ID# /// ft. g- _ft r I GGG((( (((���
5a.Well Location: UJ( ft ]g('eft {O bn /� 5th--c.
=k/4A P a n Vl6V. (3(p ft 3 to,b ftPI
r/ v
Facility//OlwnnerN ne n� • Facility
(DV(if a�ppQlicable) l(�ft ft '.
• 3a.(o U iWi ( a `OUYCS�V, i"l. ft ft.
Physical Address.City,and Zip ft ft .
-Treq 1014)0.- 7 so(�u.J 21.REMARBS •
County Parcel IdentificationNo.('J(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.C 'on:
3S,S1 fri 0 N ` n•1 g ( 3 w Q 3
6.Is(are)the well(s): IlPermanent or DTemporary Sig❑a a of Certified Well Contract Date
By sio ang this form,Ilrereby cer t that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L INo 1SANCrIC 02C.0100 or 15.4NCAC 02C.0200 Well Cons/motion 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 beenprovided to the well owner.
repair under#2I remals section or ate the back of thisform. 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 ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• drilled:124.SUBMITTAL INSTRUCTIONS '
9.Total well depth below Iand surface: 10 0 (ft) Submit this GW-1 within 30 days ofwell completionper the following:
For multiple wills list all depths ifdi ferent(example-3@200'and 2@100) 3P
(� 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: J (R') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)Borehole diameter: (m.)
Program,1636 MSC,Raleigh,NC 276994636!
12.Well construction method: rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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
13a.Yield(gpm) Method of test: air PemmitProgram,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine I 5 02
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Enviromnevtal Quality-Division of Water Resources Revised 6-6-2018