GW1-2021-00728_Well Construction - GW1_20210401

Kor Internal, se Clttly:
1.dell Contractor Information:
Christopher Wachter 14. A'T= s
FROG! rO a ru ON
Well Contractor Name
t.ac®ar.
`.ow•� r't. t�i.
M:k1jeUCor tifieaGon lumber flS�OU7SR"iCA$INC'for wdM QR 1rIl�R` a blo
Cummings Developments, Inc. 15 �o n TItTCCQVt�fi �Ar�TAra
+1 ft.
Cwnpany Name
Well Construction Permit#: a D l 7- 3�J y�L N Id R �OR 7 t7lfiMG a alga
2-,l7_ trROm 'r0 jDTAtR TTrtC4Ca2�a t aT 4ar�
�:Well-l:I�( �sll nee�t fr. ft. in.
w
eSupply Well: 1%SC13ul N
ltttTal e+RAPA a A I 'ru MMMM UA'tMI,&t.
Municipal/Pubiic R. f, to
emtal(Hesli 410tioiing Supply) Residential Water Supply(single)
R?S1ttpP±*iQ!l�rr�tssertse fst a;frn �
on _ TOPJAMIAL
I�TOn- �tex gttpp9y�'�la 0 % 20 yt,
Mats' POPt Cs$!7t@tit POUF
Recov Itp, M
Injection wen:
quifer R R'
�� Groundwater Remediation
quifer Storage and RecoverySalinity Barrier 14.SatIWGRA�iE1;PAt bte
-t
d, cal UStormwow Drainage..93Subsidenc a control 6t ftrmal(closed LaoP) (3Ttttcerrmal(Hearin lin Rerun► er( n undo#21 Remarks Mira attscattrrtoit r apsdaa cetvrosk e,. etc
C Date wal(o)Cam : - 'Z1 well ID#.. _ 1. $`� & n a ti ol. a c0) c.
So.Well Location: ft. 0 L,p o• �
ic+1� MLA o'
Faeilityl()wm Name Facility lDO(ifepplicable) D- %
Physical AAMM ,and lap
c2 2'l.ri►1 ao al.ltMNAR S �k'.
Couaty cot glib .
Parcel Identifiiatiaa No.(IrIM
Sb.Latitude and longitude in degreesminntessesoada or decisa dc�ree&:
(if MR field,one letliong is sut{icieat) 22.CWdfileado
a=r.ikari e)tug Waumcgremanent or UTemporary st of ell Cc' Ct--- Date
R this farm,/hereby cepr(fy that the evetl(s)rMff t1 earncrraeed In accnamtee
7.Is this tt repair to an eSlS ag welt: [Oyu or 101% ,vith 15A MUC 02C.0100 or 15A MUC.O2C.0200 Well Construction SYw dar&and 6ral a
{/this 19 a AWir,Jill oat koaoaen—11 construction h{fmmation and explain the natum oflhe copyrfthis nwrdhats been provided to the well otmer,
repair antler 621 remaAW section or on the hack ofthis form. 23.Site diegram or additioncl well detatts:
8.so�r.GeoprobeliplPT or nosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
.
`3T.Mon.Oulu I Ovir..}k eS.^A-Arrt rR/'ri sLtuT •�:.�.:`Ze Fi:r:. - :R: ..t:a nin ✓ ...... ....w.. :.
orrrreo:9. _.-•- .. .. .. ............... ___.p-y-q.�...-ep.... . �s�rp/��,r�+ ...._.._._...,:y.:;�."u...avwuwir.
/�� a7jl 6'll M�tiA�j��^4J0../l E1tJ1A51r'4
m well depth below land surface: M) MO.�tr ill�yeps; Submit this form within 30 days of completion of well
I%ortnultialllple wells psi all rksplhs{Jd j(ferant(rumple-3@200'and 2@1� construction to the following
10.Stotle water level below mop of easing:_ (k1o) Division of Water esgu
If hater level is above ew/M ease" R roes,Information Processing unit,
16171�tall Servim.eplitor.ilaiAgplt.
24b;ftr ggicction Wells: in addition to sending the fottn.to the address-m 24a
M Well;conctraetion • RoWry above,also submit one copy of this form within 30 days of completion of well
(i.e.auge,wwy.cable,dkm push.etc.) construction to the following:
FORWATER SiM1PLY WRIT ONLY: Division of Water R MTM,UndaVvend injection Control Program,
1636 Nag Service Center,Raleigh,PIC 27699-1636
133.Vi dd(Spm) Method o5t6'sat•Air Rotary
2AC.For 95l_
r.4-r.h`:rn-M n Brie,•. C-sr-.1.. i-.. .. '.::.......... -
13b.Disinfection the address(es) above, also submit one-copy of this form within 3Of days of
43'P¢: amount: 2.o z compleUm of±mil instruction to the co=W haft depmftew of the county
where constructed.
Form OW-1 MorthC'amlina Deparnnent of tinvieoasae,ntal Quality-Division of Water Resources irmAtsut 1_11f-en.
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