GW1-2023-00464_Well Construction - GW1_20230109

1.WkUXontractor lion:
' •I4:,pTATERZOI�S�.". .
Well ContraQtorVarne nom TO DESCRIPTION
ft. ft
ft ft.
NC Well Contractor Certification Ntombet
15:O0 cERLdSING,(fo`r mnIfi=rasea we31s)QI2L'IIR
Morgan Well&Pump;Inc. = FROM I TO I DIAMETER ' Tmcmi s MATERIAL
CompaayName +1 ft 6118/ In. sdr21 pvc
"�y' 2C In:INII�IR G012•TUBII�G:"enth"e"r'ma7cln'se3-ion"f;:"a.•;' '•;;•;,.;;•:'.
2.Well Construction Permit#: `��+J FROM TO DTdnBru:u I I THICHNEsS I hATERIAL'
List all applicable well construcfionpermits'(ie.UIC,Cowtty,State,Ymiance,etc)• >} ft
•3.Well Use(check well use):
fL ft in.
17.-SC REEN',=::
Water Supply Well: FRotvl TO DIAMETER SLOT SITE THICKNESS rivinTExrAL.
t Agricultural r—IMunicipal/Public g. I .
Geothermal(HeatineCooling Supply) f Residential Water Supply(single)
ft ft in.
1 Tndustria]/Commercial I Residential Water Supply(shazzd) :.'18'
-GRO _ __:,• _Kid tion FROM TO MATERIAL Eryf? CEMENTMETHOii&AMOIINT
ater Supply Well: o ft 20 ft bentanits- poured
Monitoring. oRecovery ft. ft.
-Injection.WeII ft ft.
er Recharge �J Groundwater Remediation
:.19:S�ND/GRAVELPACI{(if "linable
er Storage and Recdlveiy nSalinity Bawer FROM TO MATERIAL EMPLACEMENT METHOD
er Test 0Stormwater Drainage ft. ft.
mental Technology Subsidence Control ft ft
ermal(ClosedLoop) 13Tracer .D1Lrmal(Heating/CoolingReturn) Other(explain uadea#21 Remarks) FROM To DESCRIPTION(cold,baroness sotUrocktype sae ete)- -
4.Date Well(s)Completed:' Well m# t 5 ft ft
Irk
52. ell Location: Cj ft.
oc, ,ll ft ft
Facility/Owner Name Facility ID#(ifapplicable) 'sit. bJAN O 9 2
9 •TV\7, yr l
Physical Address,City,and Zip 1 � ft ft :rtSF�.�
��'��`� ���� J(� i(L I I L/ �2Ie-R'1::MARTCS�`_ .._ '_- _ - _ - - _.,"i..'• -' t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 cation:^`
3�.5a%a. N �b• � W MIN I22
6-Is(are)thewell(s)Vermanent or OITemporary, Signa e f edWellContractor Date
B o ring is form,I hereby certify than the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or.0No wah 15AN C 02C-01D0 or 15.4 NCAC 02C,0200 FFeII Construction Standmdr and that a
Iftivs is a repan,fiII out known well cons6vction information and explain the naiure of the copy ofthis retard has been provided to the well owtrer.
repair under#21 remark section'or on the back ofihis form.
23.Site diagram or additional well details:
8-For Geoprob'e/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7'05 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#-diieretrt(==.pie-3 20D'and 2Q100) construction to the following:
10.Static water level below top of casing: 030 (ft) Division of Water Resources,'Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (m.) 24b.For Infection WeIis: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction metpu d: L� construction to the following:
(ie.auger,rotary,cable,dsectpusb,etc.) �
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,R Ieigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SumDly&Infection Wells: In addition to sending the form to
the addresses) 'above, also submit one copy of this fog within 30 days of
13b.Disinfection typ Amount: ✓)n� completion of well construction to the county health deparhnent of the county
where constmbted_
i
Form GW-I Nortb Caroaa Deparbnent ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
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