GW1-2022-07603_Well Construction - GW1_20220817

Unit
1-Well contractor Information: RE For Internal Use PHtItFom
CHRISTOPHER WATCHER
Well Contractor No 0
4448A IRON To DESCRIPTION
NC Well C
Certification Number &
CUMMINGS DEVELOPMENTS,INC K JNQ_Ifr.,��_­_im i
Company NUMg FROM TO In id.we .0R-L ER h—
+1 BUR 7W1 tATERIAL
2'We"ConstructionPennim Gets Ilh Q ISTEEL
UelalLapplicable wj z-c) OR TUB]NG; Be
County,state, Om rO G
thvmalldotedyoo
3,Wall use(check well use): etc.) 1A R
Bass MATERIAL
Water Su tn.
ft.
Agricultulai EN_
Geothermal
(Heafl Muni l0al/Publc PROM DI I
Ind /CnguPPIA ®Residential ft.
C us
UPAY Lusttisycmmercial (single) 11L
bd tiol Residential Water Supply(shared) ft.
In.
On-water S ply 1:
ON!
Monitoring 0 ft. MATERIAL
action Recovery 20
FORT CEMENT POUR
Aquifer Recharge fL
Aquifer Storage and Recovery E3GMundwater Rem0diation IFL
Aquifer Test alinilyBarrier NDI
Experimental Technology, 0stormwate,Di.. n TO 51ZIL.
L
IL M 01)
Geothermal(Closed Loop) 0SUbsidence control ft.
Geothermal DOI' Leturn) OTracer 20.DRILL-ING LOG IL
.n a -
other Plain under#21 Rem om ell' 7
4.Date e ft DRSCRI rcefor IMMU ............
8 COMPI0ted:1_7_Z WellID# IL etc.)
52-Well Location.- ----------- 17
Fee Nama &
IL
Physical Address,City,and 4
.................. ..........................................
..........................
L ft
County 1q7 21. hA
%
5b.Latitude and longitude in degr I%rfti Identification No.(PIN)
(ifwall field,one IM00i is sufficient) ee,/0"WeAllecOnds or decimal degrees:
I
6 1 9. N 22f 22.Certifica
6.Is(are)the well(S)OPerim"clut or t3Tempqrary �W
Swgnaturc Iffd W011 Contractor
this 8 repair to an existing well: Date
flhLr ft a rej j711 old kno Im Ivell= ®Yes or Jallo 41"Ing this fornt,I her-4,­0 laffi the well(,) (w,
POWIP under#21 rentapk sijan '"t"ne4lon l4tort"allon and,ploju 1111h 154 NCAc 02C 0100-115,4 NC.4C 62 F-)"filtructed lit acv,-Ordefte,
C.0200 &M
or On the back ofjjj1,f,,,. nalum a 0 coRy-fthis record Z;h"11,Pravided to i4e Well COutin"1111 d jt,,jdjjjoj,,
8.For GeOprobgjDpT hell
or
construction,only I GW I Posed-Loop 23.Site diagram or addition
- Is Geotherund Wells having th YOU may u al Well details:
drilled needed, hulicate TOTAL NUMBER e same so the back of this page
Of wells to Provide additional well site details or well
cOnstniction details. You may also attach additional pages if necessary,
9-Total well depth below land surface:
F"rmufttle writs I&IalldipI&
24a.
&LALW Submit this form within 30 days of completion of well
10-StItle water level below top of casing. construction to the f011owing:
y"Wrel 10MI is above 11113,IN,"4- (ft.)
11-Borehole diameter. 6 Division Of Water Resources,Information processing Unit,
4an Service Center-Ralaigh,NC 276MI617
'6'7 r 12.Well coostrOctiOu Method- ROTARY 2 4 b.IF
or auga, above, : In addition'
to cable,direct pus;, lVe also to sending the
etc.) it one c! form to the address in 24a
following fO I nn within 30 days Of completion of well
construction to the f opy Of this
FOR WATER SUPPLY WELLS ONLY.
132.Yield(gym) Division Of Water Resources,Unde I iground Injection Control Program,I(gpm) ZZ 1636 Mail Service 1
l3b.DisinfectionHTH Method of test: AIR ROTARY 24c.F Water
Center,Raleigh,NC 27699.1636
fater At F;) : In addition to sending the f 50
type;
the addes!s—ta..1 orm to
Amount: Ma z Labove the submit one copy of this form within 30 days of
Z
Completion of well construction
Form Gw.j where constructed. On to the county health department of the
North Carolina DaPartniant0flinvim"Montal Quality-Division ofWatcrResources county