GW1--06510_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j ,
1.Well Contractor Information: I
Chris Morgan • 14.WATER ZONES
TO DESCRIPTION Well Contractor Name FROM TO
3572A 1.1,6
ft. 'lip0 ft
ft. ft
Na Well Contractor Certification Number •
15.OUTER.CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 2 ft. 16,1/8m
Isdr 2 i �.P�/(�
q t q,_-jc O��� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1{VO 4 PROM ' TO DrhMETER THICKNESS MATERIAL
List all applicable well consintction permits(1e VIC,County,Slate,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 DM cipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) {t ft in •
Olndusfia]lCommercial • DResidential Water Supply(shared) 18.GROUT
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTh1ETHOD&AMOTINT� •• _
Non-Water Supply Well: 0 ft• 20 ft bentonite poured E�-- �.,�;t,;;, ;;'
OMonitoring DRecovery ft. ft
Injection Well: NOV 1
DA erRecfiar eft. ft (O24
. i
q g 0GroundwaterRemediation
DAquifer Storage andRecovery OSal in ity Barrier 19.SAND/GRAVELPACK(ifapplicable) iT: :;..s.i: ;.- .,�.s: „
FROM TO MATERIAL Et1�LACEMENTMET$OA:'lz: %,'r;. ..' '•'kt
OAquifer Test OStormwaterDrainage ft ft y`�
DExperimental Technology OSubsidence Control ft ft
OGeothermal(Closed Loop) • ❑Tracer 20.DElEtING LOG(attarir additional sheets itnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(colcr,hardness,soiUrocktype grain size etc.)
aa//�� 0 ft ' b ft. 4/.
4.Date Well(s)Completed:1i )I I1 WeII LD# • �l ft Li J ft r�'C� c/J Q 711'La
5a.We Location: (�� ft. 3�ft � '� `x�" `�"
Stil CtalTiVititOk ft. ft
Facility/Owner Name
. Facility mD#(if applicable) ft. ft. ••
• 1LN1 Cask( V (j " trl r1/ c f if/ ((i ft ft.
Physical Addieand Zip ft ft.
SS 21.REMARKS •
County Parcel Identification No.(PIN) .
5b.Latitude and longitude to degrees/minntes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) h pp '/ 22.C anon:
'3SlSId3 ( N -TO' 02Y"set° W /°/ ?/
6.Is(are)the walks): LSPexmanent or OTemporary Signature of Certified ell Contra r J Date /Z
By signing this form,_Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or I lNo 15ANCAC 02C.0100 or I5.1 NCAC 02C.0200 Well Conshuction Standards and That a copy
If this is a repair,fill out/Drown well construction information and explain the nature ofthe ofthis record has beenpt ovided to the well owner.
repair under#2I remarks section or on the back of thisfoim.
•
r 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:
3 0 24.S UBIb41TTAL INSTRUCTIONS I
9.Total well depth below land surface: ft
For multiple wills list all depths ifd�erent(example-3@200'and 2@100) •( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 m, 24b.For Injection Wells:Co
( ) pY to DWR,Underground Injection Control(IUC)
rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 'y 24c ForWater
(ie.auger,rotary,cable,directpnab,etc.) Supply and Open Loop Geothermal Return Wells:Copy to the
county environmental health department of the countywhere installed '
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
l air
Permit Program,1611 MSC,Raleigh,NC 2769911611
132.Yield(gpm) Method of test:
13b.Disinfection type: granulated chlorine Amount: I t Qj 1 '
I,
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018