GW1-2022-07593_Well Construction - GW1_20220817

WELH.C®NS1'ItY1CT'ION REC W 1
1,Well Contractor information.. For Internal Use Only: _ Pr1nt FOm
CHRISTOPHER WATCHER
WcI1 ContrectorNamc :14:lVATERZONFS._-
4448A 0M TO DEBCRIPTLON .
R. R,
NG Wcll Contractor Co1111-1ton Numbor
CUMMINGS DEVELOPMENTS, INC R.
_'18.O11TERCASING:for mnitt:caeivilwellii'i :Cumpany Name FROM TO BIAMETBR OR LINER+i'a Able• ,` _
at R. � TRICKNBBS iMATERIAL
2•Well COnatmcdon Permit#: y I B 6/8 In. .1BB Q.STEEL
LIFt all app/trable we/l ronalrurlton pennNs(l.e.U/C,Chun lq Varianrr.etc.) 16rINNER CA'8ING"OR':T.UBING;
PROM TO DIAMs1EtrdoaedaGo
3•Well Use(check well use
R. TmcK81E8s MATERiAJ
R• in. L
Water supply Well: R.
R 1136
Agricultural 17.scREEN.
Geothermal(HeadMunicipal/Public rutoM TO J
ng/CoolingSupply) sidentialWaterS it DIAIaEtin. er°�s nM 'MArawAL
lndustrieUCommerciai Supply(single) lO.
Irri lion ltesidenfial Water Supply(shared) R' Ito.
Non--Water supply aE.cRouT
PP Y Well: PROM 'ro _ MaTEwAL - -
Monitoring o fa E PLACEMENT METHOD AM
eehon ; Recovery R. 20 R' POW CEMENT POUR & OUNr
Aquifer Recharge R.
Aquifer Storage and Recovery 00110undwater Romediation
Salinity p
Barrier 19:SAND/Aquifer Test PROM fIRVEL, ACg,
Experimental Technology �3tornrwater Drainage MATERIAL
IL R �'1'MBTNOD
Geothermal(Closed Loop) Subsidence Control
n-acer R' tL
Geothermal e8' Coolie Rednrr 1A.DRIDLMU LOG a`ttaeh addlDonW hce>y;tf iuces
Other(explain under#21 Remarks room To
4.Date iVeli s e D1� oN reeror Garda aNvmck
() mpleted:�'�.Z"Z Z 11. 7 fL n etc.)
---._. R.Sa.Well Location: Well INOft.
R. ft.
Facility/Own amo R, _ «�
ft.
11 851�
Facility lD#(iferplicablc) '
R. & ,. 2
Physical Address,Cily,end Zip
u`^�.v, %
County 0 21:'ItEMARtrat Itl(vr� '�
Parcel ldwaftcation No.(PIN)Sb.Latitude and longitude In d
lif wall field,ono lat/lo ��es/mipsJseeonde or decimal degrees;
ins is aufKciom)
""'O�d• l g Z t N '� D 2Z • (,f f I 22.Certnic
6.Is(are)the wells() W
Permanent or E)TemporarY
Signaturo 7.Is this a reps.toan existing wen: of Contractor oerc ---
®Yes or ONO signing thir fans,I hereby cerl(�y that
the we!!(s)ems
lflhls Le g repair,Jill au/rsevil tvorontheback i,�ornragon and explain the aartnr oflhe raPY lihHMJSAis�eco d has been p,nSA IIII�e 2C.02 0 Well Conslr7rcilon Standards gild Niat a
repo/r under#2l remarlrs aerlion or on the back ojiMsform. (Weiv)eonglnteled la accordance
r.
S.For GeOprobe/DPT or Closed-Loa 23.Site di
construction,Only P Geothermt Wells hunt the same diagram or additional well details:
y i G6V_1 is needed, Indicate TOTAL °g You may use the back of this page to provide additional well site details or well
drilled: NUMBER of wells construction details. you may y also attach additional pages ifnecessary.
9.Total well depth below land surface: / VXTTAI-rn►a'rner�,,,,��
Formultlp/e wells/Isla/l de!hs'd'p /l'rQererg(ezaap/p.3Q2t10'aid2Q1009 24a, a
10.Static water level below top of casing:
3� constructionlloSub
1.Borehole diameter: it this for'in within 30 days of completion of well
//'anater loyal Is above rasing,rice'+' (ft)
Division of Water Resoureea;Information Processing U014
1
(in.) 1617 Matt Service
Center,Raleigh,NC 276"-1617
1?r Well construction method: ROTARY 24b•)FOr Inieetimn Welrc: In addition to sending the form to the address in 24a
(t.n.auger;romry cable,diner push,eta.) above,also submit one copy of this forte within 30 days of completion of well
FOR WATER SUPPLY WE construction to the following:
ONLY: Dlvlslon of Water Resources,
138.Yield 1636 Mail Service enter,,mound InJection Control Program,
(gPm1 Method of test AIR ROTARY gl+,NC 276".1636
13b.Disinfection type; HTH 2�' 'g mat r Suenly r , 4
-- "—`tr°°hteila: In addition to sending the form to
Amount: p Z the address(ea) ab v, als su mrt one�C0
completion of wall construction to the county healthsde ailment of lhedcouno
Form GW-1 where constructed.
North Carolina Department ofEnvironmontal Quality.Division of Wator Resources