GW1--06485_Well Construction - GW1_20231002

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WELL CONSTRUCTION CORD(GW I) `Piaui ct TUst Only: - - I --
, I.Weil Contractor Information; - •
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NC'Wv1t C' �terCertifiontiantimber— _ k . --
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Morgan Well,&Pump,NC ..M To IRAMz ER =MESS MATERIAL
-.-.-. . ._.. — — `'C... -- 0 ft' 1 ft. 0VP ' st!F31 PVC 'r
Compi ensue?e 6ATINEWCASINOOR'1:IMMTO t1'ndleina'wlstoaed-n:•"7•Y�• :
2,Well Construction Permits 1!Olf. U t1ROM TO _ �Ixttt:t ss nan�rrnttAL _
Manilnppllcrtble well conch omper dir(l g Uteri CQynRy variance,ease) ft, ft, le, •
ft ft, le, .
3.Well Use(chests well um);
Water Supply Well: FROM ToDIA:MEETER ] �e e Tltt EES MATERIAL
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Ciaothemal(Iileatin$lCrsoling Supply) Residenliai Water Supply(sib) ft, — -- ig,
IFOUVASYCOMDMid DRoldaltial5'yAlcrS?i?131Y sitar GROUT .2 ,,:r.:- :, c :a,';: :,F;; A•.:
Irrigation FROM TO MATERIAL -' EMPLACEMENT METHOD ec A. +ueT
l Nou Water Supply Well: q fss ft pmo
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Monitoring DRsegv ft,— '
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Dr1q>,Sfct ltscha ©�l{cilictilat�att ::=
�.1'ltiSA1'1111Gi$AYEL'�At� t`miipft€able} _ ..•.
DAqulfex Storage tmdRecovery CiSannisyDenier erratic- TO - MA L EMI'LACEMEPi'raiernon
tufer Test ft,_ �`3totw4tExDsat°ag`
Experimental Technology
tRo EjSubsid_enee Control h`
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Geothermal Loop) ;:2o nxnavvGze>G:csc anei ►a le -.:.:
OM TO - n iPT cookr.kihit sayrost me,groin am,Ru.i
} e0tllstinat Mediae:ogling 'Z�2�ldtsr(sxol_ t der__tuna_sl 0. ft, JD r l, �J` I ��
4,Date Well(s)Completed: i 1,a ►vell Loy _- 11D 1. Z� 1 / 6 t ll d,r F
ga,Wen Location: 23 n' cb `t,. pro/mil
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FnoilitylOvuuNulne Facility 10#0fapplielbtc)
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County ty Psasel fdcntiticadon Nc.(PIN)
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6b,Winds and longitude i.p degrees(mSnute/seconds or decimal degrees: - fjr., .J 0fia
twel field,one IRylongis sultciect) 22,Certifications
6.Kate)the well(44Petnansnt or f Tensporary _ 'n aSI1/g4tCtinhagier Pats
liy Mining Air farm,I hereby cc?*that the!wrll()Km(crre)sansiruslcd in neeordanen
• 7,I3 this s+repair to an existing well; Ella or Eli io with I5:1 NCfCWC.QIPP or Al NCA4 02C,.0200 Well Co_nrinnllan Standards and that n
Ifilgr 1:a repair,•fdl nue known roll wnorMetlon*minim cud explad srAsmorn Om copyelre r rggoi has brrtrgmel_daltm the taIIdK
rspglrrarder821rtatarka riattr,rantiae bank DOLT Arm 23,fitsdiagramorad_ditiouttciwell4ift1N;
S.For+Geoprgl s/Al"I or�7ss E!�op Geothermal Wan�avios the sates You may tt c back of this pose to pmnds additional wellsite-detai.Is or well
nomination,only I OW-1 is needed. Indicate TOTAL lillivlal 13,of wells construction details,You may also attach,additional pates if necessary,
drilled:' SUBMITTAL.1NSTRUCCIUOIS
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9,Total wen depth below land surface;_.... J --- (fs•) 24a,for All Wells: Snbtnit this ftite!t wititio 30 days of completion of well
- For rwldpirwelk&roll dspth:ifereferrne( mpk'3e2VO'nun2610 constiwion to the f011O vitir,:
10,Stage water lsrst Mow op erasing: ®. (ft,) Division of Water Resources,Information Processing Unit, -
limier keens above caste&um"4" 1617 Mail Saida Center,Raleigh,PIC 276991617
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11,Sorelmle diameter: 0;4) fib,For Iaie etiart 1YeUs: Tn s dditi9la to sc,idinli 01n.form E9 the address in 24a
• above,also submit one copy of this fb n within 30 days of completion of wall
12,Well construction method: rotary_ __ --- _.. entt3truetlan to tiva Mowing: I.
0.4.,now,m°sy,sn4k,dirotptub,ilc-j
Divi51o1i of Water Rssaarces,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Malt Service Ceata,Rakish,Tim 27699.1636
13a.TWA(gpm) 11) Method of tan HIr 24r;•For Water Snooty&Infection'Vence Zn addition to seeding the Essen to
f) die addrsss(es)above,also submit one opy of this loan within 30 days of
13b,Riainftcetion.lype;9.�n,"4t attne _ Amount: l4 •'5 07. completion of well construction to ties county health department of the county
_. where constructer?
FrmGW-t Northacolins Deparusentof Environmental Quality-DivisionofWalerRucstrsss Revised2222016
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