GW1--03017_Well Construction - GW1_20230306

1.w ontractor Inf •ration: I I
14..WA.TERZONES
Well Coa for 1=e FROM TO I DESCRIPTION
I ' ftft. ft
NC Well Contractor Certification Number
t IS.0UXKR,-GSA.SIN9.(foi x2adtVaseaweus)Q12T R(ifa'&edhle)':s
Morgan Well&Pump;Inc. FROM To' DIAMETER TH[CTSiYEss MATERIAL
Company A ti fr 6 1/I/ In' sdr21 pvc
P Y Name /F/TV_
16.�TER G OI2•TIIBTNG. -e6tliermal-cIo'se3lod`
2•Well Construction Permit : FROM TO DIAMETER I THICKNESS MATERIAL' ~
List aIt applicable well conch action permits a UIC,Couuiv State,Ymiance,eta) ft• ft. in.
3.Well Use(check well use): ft ft. in.
UAgricultural
Supply Well: 1�"SCREEN:
FROTT TO DIAMETER SLOTSIZE -yT=Faims MATERIAL.
Mnnicipa]/Public ft. ft in
ermal(Heating/Cooling Supply) Residential Water Supply(single. _ ft in.
rial/CommeTeial 1 Residential Water Supply(shared)
Izri anon FROM TO I MATERIAL EMP CEMENTMET$OI3&AMOUNT
Non-Wafer Supply WeII: t tft2O fL hentoniL= poured
Mori#oring. MRecovery ftlajection.well: ft
_I Aquifer Recharge �GroundwaterRemediation
. .•.7.9:SgND/GRAVEL'PACIt ff a"liczbI'e •':.;;_• •,' ••• •' -•.•.- �..
Aquifer Storage and Reed very DISallnity Barrier FROM TO MATERIAL EMPLACEMENT I=:OD
Aquifer Test 0stormwater Drainage ft ft..
Experimental Technology OSubsidence Control ft ft
;Geothermal(ClosedLoop) OTracer ;20.DRU�TGS:OGattacli-addi@orialsliee6jfiiecess! (' 7:- _
Geothermal(HeatinglCooling Retum) . Other(explain under#21 Remarks) DESCRIPTION(color,hardness,soiUrock type grain s ze etc)
r. $ .
4.Date Well(s)Completed: Z �yeII Ip# ft ki
5a WeII Location: ftFacility/OwnerName Facility1D#(ifapplicable) ftAZC%k IVC_2�bsz; ft. - -
Physical Address,City,and Zip ft. ft.
S '21i-RF.M6RTIR�:';:so--9`:r". ,• _ _ - _- 'Udet..+_tt•F::'.-':v
'County Parcel Identification No.(P1N)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tiwell field,oone`laWong is sufficient) qSig-na
cation: ^ 2
6.Is(are)thewell(s)V,-Xmanent or DiTemporszy f rtitiedWellContractor •Date
g is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or *No with ISA C 02C.0100 or 15A NCAC 02C•.0200 YPell Construction Standards and that a
IfUiis is a repair fill out known weII construction information and explain the natui e afthe copy ofthii record has been provided to the well owner.
repair under#I21 remarks section or on the back of this 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 if necessary.
drilled:
STIBIVIITTAL TNSTRU(TlnV.R
9.Total well depth below Iand surface: W (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdierent(example-3 tt 00'and 2@100)
construction to the following. '
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casing,use I6171VI22 Service Center,Raleigh,NC 2769E-16I7
11.BorehoIe diameter: 6 (ia.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
~12.Well construction method: d (J above,also submit one copy of this form witbin 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
E13b.
ATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
eld(gpm) Method of test air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fomi within 30 days of
sinfection typ Amount: OZ completion of well construction to the county health department of the county
where constructed-
Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016