GW1-2022-05934_Well Construction - GW1_20220627

WELL C
For Intern#[Use &M,
L Well contractor Information: y:
CHRISTOPHER WATCHER
W-11 C-Irtractor N_.... 14 KA
FROM TO
448A ft.
NC Wcll Contractorft.
In Number
SlNG
CUMMINGS DEVELOPMENTS, INC FROM J9-'01UTER -'_rATO ,1 f WORM, ZIRt-L'INE
canip I.Mc DIAMETER isle
+1 ft, ft. MATERIAL
6618 In. *
2, .188 (3.STEEL
Well construction Permit#. 5?-=n Ltd 0-K)'L7- 16ANNE&CASING01t:TUBING'
'eotherittal closed-trio
Lis,all aPP11rabJe well.rans1,n,11,, County,.State, FROM TO DIAMETER
ft. THICKNESS MATERIAL
3.Well Use(check well use): ft. In.
Water 11,Supply Well: ft• ft. in.
Agricultural A%
1 71:11.2 TO
E)Municipal/ftblic a S
SIZE 1C Geothermal(Heating/Cooling Supply) Mi1esidenfial Water Supply(single) ft. ft. flu. lV1,4TERIAL
Industrial/Commercial
rM lion E]Residendal Water Supply(shared)
..ORO
Non-Water Supply Well:
FROM TO L C
fiL 20 ft. E E INT METHOD A AMOUNT
Monitoring 0
Injection e Recovery ft. ft. PORT.CEMENT POUR
Aquifer Recharge 13Groundwater Remedi2tion
Aquifer Storage and Recovery E)Salinity Barrier -19„SANDIGRAIJPE, I!I, I Is ic,51
Aquifer Test FROM TO MATERIAL
13StOralwater Drainage ft. ft. CE M-STMETROD
Experimental Technology
Geothermal(Closed Loop) 13SUbsidence Control ft. ft.
Mracer
Geothermal eating/Coo1. 11 --20;..DR XINGLOG Rtheb:ndaivional,sheiMiff.n,,"i Ing ettim) explain tinder#21 FROM
Remarks) To
4�_J � DESCRIPTION(co
rMa
- ck
4.Date well(s)completed:A2LLE_Sz 1K. -4 ft.
"Well 1D#----------- I? ft. ft
Aa-Well Location: It. ft.
ft.
Facility/OwnerI�Nalmel"��t 'O�'Ynl ft.
N'E
Tou'l G Facility ID#ffa—ppll.bl.) ft. ft.
Physic a. ft. 22
Address, Ly.and Zip
ft. ft.
county `� II 9 3 Ib 11'RENARn.
Parcel Identification No�(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds
(ifWall field,one latllonr or decimal degrees:
is Sufficient)
1 0 22 c Ilia,
o 'rt
6-13(are)the welf(s)0prinall,lit iq
or oTemporary Si rare 0 ed Well Contractor ZZ
7.Is this a repair to an erjsting Well: 13Yea or Jallo . ng IllivJ ,1 he"Chv c-10 Ilml the well(s)was Date
n n 15A NCA C 02C.0100 or 15.4 NOW 02C.0200 (WOM)Constructed lot accol-dance
PV'thiy is it reprJ11.'flil oil/k"Dwil well cansn"'clia ful"I'allon and etyplain the nature oftle cOPY Offfils record has Well C01'sh"'clial Slmd,*and ffiat a
V41P under#21 remarks section a,.oil lbe back 0f111,9f
"eel'P"OvidedtO Ille well owner.
23.Site diagram or additional well details:
S.For GeoprobeADPT or Closed-Loop Geothermal Wells having the same YOU may use the back of this Page to Provide additional well site details or well
construction,Only I GW4 is needed. Indicate TOTAL BF
NUM 'p
drilled:----------- of walls construction details. YOU may also attach additional pages if necessary,
9.Total well depth below land surface: 2U1bI=&MaK=fflM
For multiple wells&I all depths ifdiffel-efft(i ranglle­3@200 and 2@100') t'j24a- For All Submit this form within 30 days of completion of well
10-Static water level below top of easing: Z construction to the following.
Ywater level Is above casing,use"+" — -------- (ft) Division Of Water Resources,Information Processing Unit
11.Borehole diameter;.6 —(in.)
12.Well construction method: 1617 Mail Service Center,Raleigh,NC 27699-1617
ROTARY 24b.For 1nJ_ee!_10_1t_WeIIp* In addition to,sending the form to the address in 24a
above,also submit one copy
('-a-auger,rut[UY,cable,direct push, Of this form within 30 days of completion of well
construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
Pin)
1636 Mug Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
------- Method of test:AIR ROTARY
=7;
14 = 24c.For Water Supply
type. V
13b.Disinfection NTH mount. a the address(es) above, 4khnketionWells: In addition to Sending the form to
Amount: Met also submit one copy Of this form within 30 days of
completion Of well construction to the county health department of the county
Form GW_l where constructed.
North Carolina Department of Environmental Quality-Divisiou of Water Resources