GW1-2021-00745_Well Construction - GW1_20210401

WE XG For Internal iJse Only:
1.Welt Contractor Hnformtation:
Christopher Wachter
m Balm
x
WeliCantractcriO me y, L
ce a
h'C:lrICHCknuactorc"fieationNumber I()ii1SRCAMt"u(forte )R'LYLiiSia s
Cummings Developments, Inc. FROM TO DIAFatr, = TO a9a7IML
Company Name +1 9L 11 7 RL 1 6,5M 4 .lee 0.8m
16. CAi11NG OR'I'>< R40 i
z. /ell Construed Permit#:_38�1�u-)2Q Fno�a ?0 D1ARM'Tan
TMC:MS Vs IaF a�re�v.
3et�e111Fse((heeiswslltese)w at. fe. {" in. _._.,
Water sapply dF a: t7.5CRO1wN
AVicultuml PROM TO F DusmMrntx I s 'rntcz EMM 'rM t.
Municipal/Public ot. % 16.
ennal(Heatiowcealing Supply) R
esidential Water Supply(single) fie tt. to.
IridushiallCommerciatl Wnterc:ma?,r ts4nrtrR
I�IOn-Watet , FRaHt To MAWRIAL !EMPIIA .p 'rdRE pte�iHOMM
'�✓ep. JL 20 ft. POOR CternMd Pour
Mani Recur R %
Injection Well-
uifer Recharge OGnaundwater Remediation
PAquiftr Storage and Recovery ® rty Le':gAN RA L PAt is
`Sakti Barrier --
--"%"AtlA ►WA ajStermwater Drainage ft. &
Tuhnowa 3Subsidenc a Control
Geothermal{Closed Leap} 03T ao i)Rdt:LtN6o Lt ai if
Geothemml eatin Coal' Return Other(explain under#21 Remarks MON TO asacsePMN
Z�ZI 0 t� !,.
4.Date Well(g)Completed:�Z� Wen IiA#- _ �1 � �I � n Ga�ss�? �p���►
59).Won Loestion: ft. j n. '
.Shli .^&
FaeilityrOurnea Name Facility IDO(ifaMlicable) '
3!y _ a �+ � - 0117 �.
Physical Address.City.and ft. ft.
COMY �tS�.e 99�3 inidirrta gory
Parcel Identifimtion No.(PR n k
She Latitude and longitude in degreedaduates wmads or decimal degrees:
Of—II field,oat w tong is Macient) 22.csertldla nelo "
l0000
6.is(M)the wm►{a)C&Permuent or L3Temporary fled Weli Gontractoz Date
y signing this farm,1 henehy ceitO that the twil(s)uw(were)omiraeded in acmrdmw
7.its this a repair to an eshding well: Oyes or Biqa ivith i5A NC:AG 02G.0100 or 15A R►('AC o2C.o200 well ranstruction 8iandan*and thin a
l}Yhis is a repair,Jill orb hnom avrll cana,udim hifatntattan and a#atn the naiwv ofthe eapyafthfe recopdhas peen provided to the uAeti myner.
repalr under#21 mnadosectian oron the hack gftlL form.
23.Site diagram or additional well details:
8.For Geopr obeM P7'or Closed-Loop Geotherin d Wells having the same You may use the back of this page to provide additional well site details or wall
«►mt�,rctlean.�s1N l C'i+t/.,t{:z^:`tta`r! r,r.1.:Ge..T^Thy�zss urrr. � :n:-Gr.. � st::....- :,..... �-.,�_.
,�S �S�°�fi'i"H'Aft�P��firl'f$Il["8`tfSI�T�
9e mufTotal well depth below land sterna(=: ��t eft,) gqa- porgy Submit this form within 30 days of completion of well
l armultiple weds list all deplhFe!(8erem(azmrtple-3(e200'mul2(rtOD} construction to the following:
10.Stone water level below top Of easing:_ ,m/ ( ) DIvlslon of dater Resoa
Ifoaterlewel is above casing we" e(ess Information prtt(essin�g Unit,
1617 t?lfail Seraia'm lf'prot(re��1?i�.iei2"fl
t61k.) 74b.&r ectiog ell=: In addition to sending the form to the addwss•in 24a
M Well..comtraeden methad: Rcftl. 'above,also submit one copy of this form within 30 days of completion of well
04.auger,rotary,table,direct push,etc,) construction to the following:
l
FOR WATE R SMLT WELLS Or%V.. Division of Water RUMUB,Undergeonnd Injection Control NOMM,
qq �} 16M Mail Service Center,Raleigh,MC 27699.106
13a.Vidd(Mm).-�� McModof&.0,Air Rotary L�L".12h C4rt.-9'R-Inniv n
i i3b,Disinfection H•H the address(as) above, also submit one copy of this form within 30 days of
I 4t'i -�_ AMCunt: O? cosrip an cif it xnstrut�on�the comay health department of the county
where constructed.
Fong OW-1 Nor&Carolina>epammertt of tinvieonmentsd Quality-13ivision of Water Resoarces itmAawt�_re,.em