GW1-2023-01406_Well Construction - GW1_20230208

1.TContractorInformation_
QC'CW clay-se. 14:.WATERZONFS r
FROM TO DESCRIPTION!
Well Contractor Name ft ft
11,5®� ft ft. E
NC Well Contractor Certification Number
` '15:OUTER,G�6STNG,(fn"r multi-rzse3sveDs)012 LII�E12 C¢'a'lisle)'�:�::':•:_'•.'.=
Morgan Well &Pump, Inc. mom To' DIANTMER; i x MS MATERUM
Company Name +1 pvc
6 11s/ �' sd 21
1,��/'� ''ff��f 1G Il�IITER CASING OI2•TUBUNG:
2.Well Construction P"It##611� � "va/�� � FROM To nIAMETER I xt�cr ss MATERIAL
List all applicable well construction permits'CL e.EU0,Cc miv,State lrarfarrCe,etc), ft- fL
3.Well Use(check well use): ft ft m
17 SCREEN •-•
',=::' t_- . �. ._
Water SuppIp We11 :t::.•t ;,.::.:`.(::� :=
FROM TO ,• DrAME1'ER• SLOT SIZE L THICKMS I MATERIAL.,•
Agricultural OMunicipaLToblic ft ft �•
!Geothermal(Heating/Cooling Supply)' Wsidential Water Supply(single) ft ft- in.
Industrial/Commercial E3Residenfial Water Supply(shared) -- = r�.� -
GROUT-.'----. _ =`....• `:"i y:,i-
;Im pn FROM TO MATF'RTAL lXMPLSCFI$NTMETHOD&AMO=
Non-Water Supply WeIl: o zo bentonite• poured
Monitoring Recovery ft ft
Injection WeII:
ft ft
J Aquifer Recharge K3&oundwaterRemediation
•:19:SAND/GRAVEL•PACg ia-"licalire '
'Aquifer Storage and Recovery MSalinityBawer FROM To I MATERIAL EMPLACEMENT`IAMOD
'Aquifer Test OStormwater Drainage ft. ft.
E"perimental Technology OSubsidence Control ft ft.
i Geothermal(Closed Loop). OTracer :Z0.DRnaMG-LOG'(ktiWT ddition'i'IsEeets_fueces's 7';
t Geothermal(Heating/Cooliug Retum) i Other(explain under r#21 ) FROM To DESCRIPTION(color,hardness soillrock tgpe grain size ete)
A
4.Date Well(s)Completed: -64 S Well ID# � o ft. a
Sa.Well Location: / 'd
Facility/Ovmee1rName (! Facility]D#(Nappplicanbl�e) /
��I��1 V►V ft
r
?hys/i�cal Address,ppCiB�M d Zip ft tt
:2A'•RM;6RTfC::••'::i'�,: '`i'•. -` _ _ _ _ - -
County PaierlIdentificationNo.(F N)
^it t7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Ykold,onel ongissur7icient) 22.Certification: •'
yt -3
6.Is(are)the well(S)&Permanent or Of Temporary Sianafire of Certified Well Contractor Date
By signing this form,I hereby certify that the iweII(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or 4,No with ISANCAC 02C.0100 or ISANC.4C 02C;.0200 WeR Construction Standards and that a
Iftkefs is a repair,frll out known well consL•uction information and explain the nature ofthe copy ofthis record has hwiprovided to the well owner.
repair under*21 remarks section or on the back of this forme.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction,onlyy I 8.For Geopro or Closed Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary.
GW-1 is needeed.d. IndicateTOTALNUMBER'ofwells
drilled:-- SUBMITTAL INSTRUCTIONS a
9.Total well depth below land surface: 160 . (ft) 24a. For All Wells: Submit this form'•within 30 days of completion of well
For multeple wells&I all depths lfdlee eni(.=.ple-3@2 00'and 2@100)
construction to the following.
10-Static water level below top of casing-_ 566 (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
I.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition t I sending the fain to the address in 24a
above, also submit one copy of this form within 30 days of.completion of well
12.Well construction method: �0 (✓` construction to the following
(ie.auger,rotary,cable,directpuslr,etc.)
E:13b.DWnfectZontype:
UFFIX WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 276991636
i
Method of test air pressure 24c.For Water SuDuIv&Infection Wells:" In addition to sending the form to
rr� the address(es) 'above, also submit one copy of this form within 30 days of
eJC qAy1 ar- Amount: completion of well construction to the civrity health department of the county
where constructed_
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016