GW1-2022-05945_Well Construction - GW1_20220627

'SELL CON111211TOryn"'THECORD
For Internal
I.Well Contractor Information: te!Only:
CHRISTOPHER WATCHER
Well COnt racror Name 14 EFZ N S .7
4448A ImOl" ft. TO ft. DESCRIPTION
NC Wcll Contractor Cortificatton Number ' ft. It. SP14"
15.JOUT CUMMINGS DEVELOPMENTS, INC ERIC."ING:
Co Name FROM TO DIAMETER THICKNESS L
2,Well Construction permit#. +1 ft. ? ft 6518 In. .188 G.SMEL
339 W 163NNEXCASIN00111111I
ING edfitefift-lieWS&I
L FROM ", -- -
TO 77
3.Well Use(check well us,): pervills 7'.e.VIC F.....ly.it-re"isfrialtre.err.) it. DIAMETER in. THICKNESS MATERIAL
Water Supply Well: fL ft.
'
Agricultmal
E)MUniCipal/1"tibli. FROM of ME.1 R SLOT SIZE THICKNESS
Geothermal(Heating/Cooling Supply) residential Water Supply(s ftft. In. MATERIAL
IndustrialiCommer,i,j esidential Water Supply sin ft. ft.
nigation (shared)
-water Supply
Well: FROM TOMATERIAL EMPLACEMENT METHOD&AMOUNT Monitoring 0 ft' 20
Injection e Recovery ft. ft. PORT.CEMENT POUR
Aquifer Recharge [3Groundwater Reniediation ft.
Aquifer Storage and Recovery E3Salinity Barrier 1-.l-9.'8AND/GRAVEL PACK Vif,--
FRom RIXII'abl' " . I-- I ,� 1 7
Aquifer Test 13StOlm1water Drainage TO
Experimental Technology Dubsidence Control % EMPLA MENTNIETHOD
Geothermal(Closed Loop) Mracer ft. R.
Geothermal(Hea gRe
tumOther(exPlain under#21 Remarks) FROM TO DESCRIPTION trnlar,hardn salUroek e. M''lu-
4.Date Well(s)Completed: Well 1D# a. ft. etc.)
ft
52-Well Location: fi. 10
ft. it.
cell t
�F. ft.
y/Owner Name MIN 9 1
Facility ID#Wapplicable))
ph ys"'I Address.City,and Zip hatil, ft.
ft. ft.
County �7S-�D i`21.' MAIM"-7_7 7
Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degree,:
(if wall field,ono,]at/long is sufficient)
3:5 05qS 22.certiricati
6-Ware)the welf(S)OPermanent or 13Temporary Signature Miffed Well Contractor 6P-
7,"this a repair to an existing well: I, S'gnlng"his fort",I hellebY ce"IYy flat the Date
Dyes or RNO ith ISA NCAC 02C.Oloo v�IS4 NCAC 02C.Ivelffis)was(Were)Cons/ruded Ill accordance
Ifthrs
a
repair Luu"d'e'0342111"'r7elml afrikisksaeoci Vill tv"11 calls""letiOn W I Ill I allon an d V.%p ja h I,,,n
01,Oro,, he back of1hisf atilre ofthe "OPY aftills record has been provided to Ih,, 0200 Well Colls"71C110H Slalldwlds and/ha/a
orla. wellotivier.
S.For GeOPrObe/DPTorClosed-Loop Geothermal Wells having the some 23.Site diagram or additional well detalls:-
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwen YOU may use the back Of this Page to Provide additional well site details or well
drilled- S cOnstiuction details. You may also attach additional-pages if necessary.
9.Total well depth below land surface: 5)0 SUBMITTAL INSTRUCTIONS
For multiple WE&fisl all depths ifdffierenj(,.ra-jjp le-50200-and 2@1-001) (ft-) 24a, For A-111 Wells: Submit this form within 30 days of completion Of well
----3s10-Static water level below top of easing. construction to the following:
F-ter level is above casing,rose .+,, -�(ft Division of Water Resources,i Information processing Unit
11.Borehole diameter; 6 (in.) 1617 Mall Service Center,Raleigh,NC 27699.1617
-LI-ek-On-Wells' In addition to sending the form to the address in 24a
24b.For 1
12.Well construction method: ROTARY above,also submit one copy of this fbm,
(i.e.auger,rotary,cable,direct push,etc-)-------------------- construction to the following: within 30 days of completion f well
.......................
FOR WATER 8 U'P'P'L'y"r-A-dub ONLY: Division of Water Resources,Underground hijection Control Program,
13a.Yield(gpm) Method of test:AIR ROTARY 1636'Vlail Service Celt ter,Raleigh,NC 27699-1636
24c.For Water Supply
13b.Disinketion type, HTH 4-1-0111-1-thli-W-22 LIS. In addition to sending the form.to
Amount. the address(es) above, 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-1 where constructed.
North Carolina Department ofEnviroamental Quality-Division of Water Rosourcs