GW1-2021-02134_Well Construction - GW1_20210620

WE 71-11 MATST-RUCTION RECORD(GW-11 For Internal Use dni—Ir
1.Well Contractor guformiation:
Chiiistopher Wachter ZONU DOMPT
Well Contractor Name FROM
1063
Mir
NC Well ContractwCatification Number wall
Cummings Developments, Inc. FFAM TO I D1MV—= TpICIaVESB
+1 1IL Ci ft. 8 5/8 400
Company Name 4S3XWtLVQ1?-O MW
2.Well Construction Pal* O NAMffn
........ 116 in.
Wl".well isso.. & &
Water supply well: 19.SIM,EN
[PAgriculturgi Qwnicipal/Publi, FPMI-- TO TAL
'i L_Gcothennal(Heating/Cooling supply) gResidential Water Supply(single) ft. fL In.
F Industrial/Conunerciai III *. all"" ft & hL I
PAING1111 TO- MATERIAL EMPLACEMENT MT1101101&AMOUWC
fL
r4on-water Supply Weil: 0 20
16"Monitoft nie—covery 11L Ott went Pour
I Injection Wen:
W-1 IL ft
11 -DAquiter Recharge OGroundwater Remediation
PAquiter Storage and Recovery MlSalinitv Barrier
Stomwa D L
'r ge'e
id.
inewal Technology
Asub rice C: l IL &
Tracer
F30thher TO >saacRerlAort odor nardaers„si0rutlt: ea
(explain under#21 Remarks) IL L
4.Date Well(s)Completed: Well 1D# ft, QJ
&
511-Well 1AIM1109: ft.
Geothermal(Closed LLM DRILLING
9 t'zft
fi% fft
Facility/Owner Name
Facility IDN(if applicable) ft.
ft. ft.
Physical Address,City,and Zip ft. ft.
0 21.a9MARKS 7
11) $
A fl. /07q?
couldy Parcel Identification No.(PIN)
Sb.Latitude and longitude in degreedminutes/wwndg or decinInj degrees:
(if well field,one Wong is sufficiont)
22.Crrtlflcad�o�n:
6s(are)tue wen(s)ox Permanent or OTemporary Date
if�M�111191ull form.I hereby certify that the ivil(s)was(were)constructed in accordance
V.As this a repair to an existing well: LF-]Ves OrON10 with 15A MAC''02(7.0100 or 15A RAC 02C'.0200 Well Construction&andar&wad that n,
If this is a'Vair,fill out known well construction Information inid uplain the native of the copy Of this record has hem provided to the rill owner.
repair under o2l reinar-tv seclion or on the back of this forrj. 23.Site diagram or additionsivvell details:
9.ror Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
rnn !t tion -w 77- 7
4-
9.Total well depth below land surface: —04 24sL For Ali Welk Submit this form within 30 days of completion of well
1-brinulliple wells/Ist all depths ifdifferent(example-3@200,road 2@100) construction to the following:
10.Stalk water kvd below top of easing: 13 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 1"d is allow effift use 1617 Mnil Service.Venter,R—alf!iA.NC 2IM-1611
iiM4 24b.ar Rulection Wells: In addition to sending the form lo die address-in 21p,
22.Well construction meduld- ROWY &We,also submit on copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,dkva;w do.) construction to the following:
V OR WATER SUPPLY WELLS ONLY. DIA8101M OfV'Water resources,Undiurground Injection Control Plop
1636 Nag Service Center,Raleigh,NC 276WIS36
lu Yield(gpo) ZO Method oft,,t!Air Rotary, 24c.For'Wrfrr Rnnnh?A
13L Disinfection type. HTH the address(cs) above, also submit one copy of this form within 30 days of
:mount: compledou of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmznr,,Quality-Division of Water Resources