GW1-2021-01401_Well Construction - GW1_20210329

For Internal Use Only: V
t,ES'ell Contractpr7rtfo -
a on:
Chris Nlor gan
/!'ell Canimctor Name
14.111,4 ZONES
3572 FRONT To pPsattrnoN
R. R.
NC hel l Contractor Canifictdon Number
R.
Morgan Well a Pulp R,
p, INC. MOAT
ew3mG(ror mol eaxd welts OA Company Name 11 TO DEUiETER t•mER(ira IlNIATE
.1 (1. TMCf01'FSS NfATERIAL
2.Well Construction Permit#: Zo2lt'-� ��+�-Z ft" stle in, sd27
List all a 5 16.INNER CASING OR TUQING pvc
PPllrnhle ur4conrrnrnion FRONT TO eothermal closed-lap
pennitr(i.e U/C,Cararp;$rare,yarrnncq nqJ DIAGIEfER THICIGY@SS 3•Well Use(check well use): R. Q- LITERUL
in
Water Supply Weil: ft. ❑. lo,
Agricultural ('—t, 37.SCREEN
ceorh ( t_yMunicipal/Public FRONT TO Dl"lEren
mural H oaMg/Ccoling Supply) Iy�,, (t SLOT SIZE TxIC10s'F.SS AIATERtAL
[itdustrial/Commercial a$nesrdendal Water Su 1 fn ta.
Supply(single)
fill
[]/Residential Water Supply it. ft• in.action pp y(shared)
Non•Wruter 5u ID.GROUT
PPI,v WeII: FRONT To
hdanitonng NIATERLIf- ENiPLACEalENT a1LTHOD6AN1OpNT
0 R. R.
injection Well: Recovery eenianile Poured
'Aquifer Recharge f—r,
❑IAquifer Stooge oGroundwater Remediation fr• ft.
g Recovery QlSalinity Barrier 19-SAND/C Aquifer Test R oVEi.PACtC Ja Trouble
Experimental Technology QlStorrowater Drainage Fnoat is NTA RIAL FatPL'cFhInNTN1ETROp
R.
Geothermal(Closed Loop) 01Subsidence Control
fL ft.
PGCDthe,,,](Heating/Cooling Rerun Tracer
20. LW TO (attach addidanal sheets if aeces .)
22 ) . Other(explain undcr,21 Remarks) FRONT To
4,Date Well(s)ComPieted:J 3 d-/ DPscmrmor rmloq naNaor,soivmryt.0 emia:�Ce.l
R. ft.
well[iY'n/8 ! _ r /Y
Sa.Well Location: �� rt' �J ft.
t?✓[aW� i
it.
W-
- r'r� n/a o h
Tanury/Owner Namc DSO ft. R •�
�l ( Facility fD:(ifaopli<able) ft. /
_'.L �QVI Y` I � LA Al I Ft.
C I of
rl .1Addtis Cty nd Zp �I.jTO-}Zt rf� tr�7� R. n ,
FJW
v[
county n/a ft.
REYARt(S
Parcel Idcntifiralian No.(PINT
3b.LatiNdee longitude in degrees/minutes/seconds or decimnldegrees: � I •l'
(ifwdl fled,one oVlong\is sureicall
N •+ -, - 22.Certification:
6.Is(are)the trau(s)OPerm
anent or QlTempornry 5 gn t fC n fed Nell Commclo,
7-Is this a repair to an G Dale �'
existing well: Dyes or E)ryo gy signing tbir/bnn.1 hemby canih r/rat the tras(mere/coutnrtred in accordance
/frhis u a er'21 v and,,,,.i,rm(/oontiroctfan infonnatfon and will'15,1 A'C4C O'C.0100 rcpeir under all mmarks section orantheback ofdastomr, mt'f°Cube nanrre oflGe mppofrliismeardhasb,,op l5:1NCAC0yC.D200:Y¢J1 Conarnrniou Standard.and d�ota prurrded1.thc,,,ad ounm.,
S.For Ceoprohe/DPT or Closed-L 23,Site diagram or additional well details:
construction,o 1 GRo ,,p Geothermal 6Vells having the some You may use the back of this page 10 provide additional well site details or well
drilled: Y t is needed. Indicate TOTAL NUMBER of wells construction details. You may also atlach additional pages if necessary.
9.Total well depth helm"land surface: .> � SLBNN TTAL INSTRUCTIONS
pavmdlipla n'efls lilt all doprlu lfdderem(clomp/e 3@20a and@1003 (Y`) 242. For All [Fells: Submit this form within30 days of completion of well
10 Static n•n[er Im•d belmr top of casing: �r� construction to the following:
f N.all,tore/is abnoa casing.use"+" (ff•) Division of Water Resources,Information Processing Unit,
11,I?orehole diameter: G 1617 Mail Service Center,Raleigh,NC 2
7699-1617
ry
rota 24b.Fol;Inle VeIlse In addition to sending the Form to the address in 24a
12.Well construction method: above,also submit one copy of this
0 e.auger,rotary,cable,direct push•etc,)
nsWction to the following form within 30 days of completion of well
:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13n.Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of rest air pressure 24e.For iVater Sunnlc E Injection Wells. In addition to sending the loan 10
granular --
136,Disinfection type: �� 6L the addresses) above, also submit one copy of this form within 30 days of
Amounp completion of well construction to the county health department of the county
Fomt
where constricted.stried.
G:'!-I
North Carolina Dcpanmcnt ofEnvimnaa nr,Quality-Division oFRraer Resources
Revised 2-2-1_2016