GW1-2021-01314_Well Construction - GW1_20210329

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I•tVell Conir-acrorinformation: co For Internal Use Only: •—•
Chris Morgan
hell COntmemr Name 14 WA
3572 Faou WATER
TOO
DESCRIPTION
BO ft. R.NC tYell ConlmcrorCettificuiOn Number
R
Morgan Well L PumpR.
, Inc. 15.ODTER CASING ormdti-w��dr
Company Name FROn( To DL1ala n' OR R [ Timbre)
C +, R. Tr2CfOJFss atATER1AL
2.Wcll'Constructinn Permit#: EM ZC) —Q Z.CY�6 6 G R s till in. sd21 List all app!/cnbfe nel/mtvrnrcrion ( I 1RNT CASING OR ITJRING(eathermni ciased.lao Puc
permitr i.a U/C,Cann(tt Smre,r'art°nc4 ercJ FRONT TO
3•Wcll Use(check well use): IL nuatRrER THICI[NESS
ft. la aU17ERrnr
Waer SuPP1Y WeR: R R.
in.
Agricultural 17.S CREEry
Gcothmmd(Heatfng/Cooling 0Munieipatupublic FRONT To
Supply) R f'1°Itfalt scorstzE mrctm•Ess lndustriallCommemial �:j. IResldential Water Suppiy(single) n I°• autTERw.
(m, ]IResidcnfial Water Supply ft. fe.noon pp y(shared) i°•
Nou•Water Supply Well'. I0.GROUT
FRONT
h'1°nitOfl[lg rr'' 0 ft. a,ATERLtL ENIPLACFJIlmc1atL'Tnoa&AatOUnT
Injection Well: oRecovery 20 R' hantonae
IT. Poured
Aquifer Recharge R.
]Aquifer Storage t—PGroundnvter Reenediation ft. R.
g and Recovery I—r,SalitY °mar 19.Sni B AND/C
Aqui Per Test �I RAVEL PACK art) Rwble)-
QI.StonmvamrDminage MOOT TO art) licaL
Experimental'rechnology "52"Cna,LTT IIETROn
QlSubsidence Control ft.
- Geothermal(Closed Loop) ft.
ITmcer fT.
Grothemtal(HeatinglCooling Retum 20.DRDyING LOG(attach addiaanat sbwbt it necass
^ ) Other(ex lain under Y.21 Remarks) FRO" To )
4.Date Well(s)Completed: of ¢C ° CRrPTrOti rotor,lundri a.auwreran c, to sbc afar
D ft• ts- ft.Well LIJ;fi/=_ ' S ft. p: k.
Sa.Well Location: q0 fr.
e f �SO
<t/tti n/a
Faailiry wnc Nam, 0 it. ft. f
-063 FaciliryrD (ifappliwble) ft. ' Pit
T OC�Y tr I R.
'11Y.1iml AddresT, ) anU 7rp 'C_U G/')con. t 0^. R. R.
ft,
County / IIlQ g/O Sy ft.21.REM (S
parcel vannecttan NO-(TIN)
Sir.Latitude and longitude in degrees/minutes/seconds or de
(if well held one lat/ong hiss sufficient) moral degrees: NIA
3����\ . 1 1C G 23.Certification:
W
6.Is(are)file woUie)OX Permanent
or QlTempor¢ry S gwt ro of CcntfEd W II Coatracmr OL.a..\.7.is this a repair to an existing well: IL�Yt LJ Dat� RY7\
ftb s is a repair,fill our Gaon",all romm¢tion fnfonrmlfoyes r and $)'signing WS fprrrt I bcrcbJ'm t�that the ue(!s war ur a m
reair under+2 Oi15A NCaC 02C.0100 or 15r1 NCAC 03C_010)Ne(1 Coer4)Celle Smlisiin umft/nca
P lramarly"section or on the back-af1h1,ja epl¢Ot the renne oflha Copp aflhir meord has boa,,f/Tit. provided in the irell ourrer.
g.For GeoprobelilpT or Closed-Looermalp 23.Site
collect: I ioq only I G4V-i is needed. Indicate TOTALVNUs haven diagramethe or k of
ageWel details:
g the some You may use the back of this page to provide additional well site details or well
drilled: ' MBER ofwclls cons]ruction details. You may also attach additional pages ifnecessary.
9.Total wall depth below land surf ace:��� SDBtYsr-myAy LN'S'rRUCiIONS
Fmnmlripfe ne//r list all depdu fdderem(em p!e 30
200 ond?@100�•—(f`) 24a. For A]=_ ; Submit this form within 30 days of completion of well
10'Static,rater level below to �//'� construction to the following:
f Me,Pere/is abet• P Of Casing; V e<ter: use"+^ (ft.) Division of Water Resources,Information Processing Unit,
il.Borehole diameter. 6 1617 Mall Service Center,Raleigh,NC 3
7699-1617
12.Well construction method: rOt01]/ 246.For injection SVdis: In addition to sending the form to the address in 24n
(i.e.auger,rotary,cable,direct push•em.) above,also submit one copy of this form within 30 days
construction to the following: of completion of well
FOR WATER SUPPLY AT,LLS ONLY: Division of Water Pes)urces,Underground injection Control Program,
130.Yield(gpm) 2636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
----�_ Method of rest: air pressure
'24e For Slater Sun Iv E fniectian Wells: In adtlifion to sending the farm to
13b.Disinfection type: granular the addreu(es) above, also submit one copy of this form within 30 days of
Amount: 6� completion of well construction to the county health deparmientwithin
of 0 county
where constructed.
Pomt GtY•1
North Carolina Depart arnt ofEnvirumacnau Quanry-Division of Water Resources
Revised 2-2•1-2016