GW1-2022-05912_Well Construction - GW1_20220627

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For internal Use Only; ;
1.Well e'onfraetor Information::,-;`'`
r 14.WATERZONES
WeliComactormMo d I To nescatFTrox
7d14 ft.
NC Well contractor CartiRcadon Number ft. ft.
Cummings.D®velopments, Ina 1s.ouTERCAsIxc or®ultiims�d eo. ORLllVE ..- :
FROM TO DfAW1ETER TH[L'IQVE88 MATEMQ
Company wane *1 ft. ) 1Y• !b q �• PVC
2.wen COM&UdonPermit#• 16.INNERCABINQ -Tt1B1NVeeotbmmehdos®ddoo ;�,, _..:•.__.
L1vf eHappllrabla tvell�onrhurl7onperm�re(fie tllC,County,Sfefe,Ym?urrce,air.) �oM ft To ft. DIAMETER T8[CttNEgg MATERIAL
3.Wen Use(check well to). ft In.
Water Supp(y Well:
�zscREEN. .,
Agricuituaal [3M1nicipaYPI eatoM To ornaaartsR BLOa f TN:CKNa69' „MATERUAL f
Geothermal(HeatinF110019 Su ) aResidential Water Sat (single) ff a.
pp1Y Supply g
lndustdaycommmeercia( ®Residential Water Supply(shared) ft ft. br.
ion upp Y( fe..t,",IROIIT _
Non-WaterSngplyWell: FROM ro zEPs , ra�LnaEWANTME imne�
Monitoring ReCOVBIy 0 f �, fr. padcament Pour
--
Be a ft. fw
Aquifer Recharge DGreundwaterRemcdiation R' fL
Aquifer Storage and Recovery [39alinity Batrier 19.9AA1D/GRAVEL PACK, n llcAblo __,ti_ <; -'='.c' `_-. -= : :_a, .•e
Aquifer Test 0Stomawater mainage FROM n. o ft KAIV-5911-
Experimental Technology �Subatdance control
Geothermal(Closed loop) Dzue1
zo:DR a;LDa wnaehoaar Geothermal iieatiD Coolie Return) Other(ex lain under#21 Remarks) 1 FROM To D�r_Ra ant rcalar tcturaere tire.etr t
4.Date Well(e)Completed: We111D# sU fa
S Well Lotafion: _
tt.
9w
FacilitylownorNeriw Facility IDO(ifopplicabla) fL & I U N
Zh to ;II rDS�e-C� I ft. ft.
Physical Address,City,aadzip ft. �• �� " +r-• r'�..' ".st,i.� nr
CA.��hS�1 oil z1 rya,
.REMARKS'.
County ParcclIdontitieafionNo.(FIN) +` A
T �G t7vr
Sb.Latitude and longitude in degreee/minutWaecoads lifWoll field,one tef/Ir� suf ickat) or decimal degrees:
f 7!tmdo
n:
N / /!. 5��1�zz
6-Nara)*0 WOR(s)IMPerManent or Temporary SmaturoofCortifled Won Co r Dato
7,Is this a repair to an erdsbtng well: es or J@No �h IYskaA NCAC dds02C.0I00 or 1SA NCAC 02C.02 Out I& O0 W'J l Consl)�onbYc dv&mid lli4 a
{fthfs Is a repah;flUon/ltneapr rvrlleonetrtrctfon lyorsratlon andexpiehr lhenntwo ojthn copy rd this rawrdhas heenprovidecf W the uvHotvner.repalrander/l21 ruaffkssedlonOpen Ihobackof hisforal.
23.Site diagram or additional well details:
8.For Geoprobe/bPT or Closed-Loop Geothermal Wells having the as= You may use the back of this page to provide additional well site details or well
colmnictioa,only 1 GW 1 is needed:Indicate TOTAL NUMBER ofwells construction details. You may she attach additionalpages iftreeessary.
driHad;
9QIBMITTAL INSTRUCTI®rls
9,Total well depth below land surface:
Formultlplea�Pll 10o/ldeplhsltdiffprent,(exon�ple-3@200'mrd2@1009 A) 240' F0C�MWIs Submit ft form within 30 days of completion of well
construction to the following:
10.Stake water'It vel below rep Of casing: (tY.) Division o Resources,Information Processing Unit,
{fwaterleva!is ebovr coaln�far°+•� f Water 1617 Mall Service Center,Raleigh,NC 27699.1617
11,Borehole diameters (1a,)
24b.For 1nte0"Wells: In addition to sending the foam to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of woll
(is.aster',ratuy.cable,oract Ptak etc.) eonstntetion to the following:
FOR WATER suppLy WELLS ONLY: Division of Water Resources,Underground Ita)ectlon Control Program,
1626 matt Service Center,Raidsh,NC 27699-1636
13a.yield(Slim) lypet6od of test:Air Rotary 24c.For Water 8annly Bs IInloetlo Walla In addition to sending the form to .
13b.Disinfection s(es) above, also submit one copy of this form within 30 days of
type• Amount:_)77n-• completion of well construction to the county health department of the county
where constructed.
FormGW-1 NorthCmollnaDoparanontofEnvironmentalQuality-Division ofWaterPesoureca Po ked2-222016