GW1-2022-07606_Well Construction - GW1_20220817

WELL CONSTRUCTION
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L Well contractor information: For—tW1j1tU Use Only:
CHRISTOPHER WATCHER
WellContrectorNa 10
FROM
4448A TO• ft. DESCRIPTION
NC Well Contractor Certification Number h & 1(.tq
I5-OlJTER'CASlNG�j`armhld;t"
CUMMINGS DEVELOPMENTS, INC ' #d 'LINER, Hiable,-49--
Co Name FROM TO DIAMETER C S MATERIAL
+1 ft. ft. In.
2.Well Construction permit - �411 Lt)�J't\)z 16JNNSR,,� ING Olt-TUD G STEEL
L"',all applicable well eowr""i. .......... OM
Penflilf fl.e.171C.county,st'," TO DIAmETIC
3,Well Use(check well use): w1e, a once,eir) ft. In. IUAL
In.
Agricultural A7 1 SCREEN,�.­; �-e *
Municipal/Public OM TO D'
IA&II11-It --SLOTSIZE
Geothermal(HeOfilIg/COOling Supply) esidential Water Supply(sin ft. ft. In. IC EssMATERIAL
Industrial/Coranterci,l P le)O ft.Residental Water SuIrri lionpply
!a.
JL GROUT:'_',
on-Water Supply
TO
MATERIAL s
Monitoring ft. 20 ft. EMPLACEMENT 'ROD& OUNT
:RecoveryPORT.CEMENT POUR
Injection :Recovery
Aquifer Recharge &
OGTOundWater Romediation % i
Aquifer Storage and Recovery 1
E)S-linityB-ITier t"19jSAND1GRAVEL"-PACK,.'if4-11 ib
Aquifer Test le T'
Experimental Technology OStOrulwater Drainage fit. ft, MA IUAL F EMENT ItE I T oD
Geothermal(closed Loop) [3Subsidence Control ft.
OTracer
Geothermal I'Heath 20.1'DR attach iddltl6fial-'Ahefi-IF UZZ
tj�VCOO!ing Return) I !Kpiam tinder#21 Remark ING LOG D
()III'let lain tinder#21 Remarks) TO E11(311 ION
4.Date Well(a)Completed: ft. % . q
sa.Well Location: Well ID#--------- 2M ft-
ft. ft.
Facility/Owner Name ------- ft. ft.
Facility 1D#(if 3% applicable) R. %
Physical Address.City.and Zip
ft. fL
County
Parcel Identification No.(PIN)
Sb-Latitude and longitude In d0grees/milltites/seconds or decimal degrees:
(ifwoll field,Ono let/long is surciont) 1 22.Certirf
iLlLf—s—N �W
6.Is(are)the Well(s)jnprmanent or OTemporary gn ed Well contractor
7,Is ft it repair to an existing well: Yes or Jallo AVIV this fo)-in,I herebv certify Date
1714il 11 a repair,fill out known 0 z 1101 the wn($)was(were)constructed In occWance
repair under#21 remarler$ftllon or on the back ofaww7n. OOPY Ofthis record has been provided to the Xlell OURer.
lvd/construction hilbrnfallon Onderploin the 0 t1ill ISA NCAC 02C 0100 or IS'f NCAC 02C.0200 Well Construe"oft Standards and I/tat a
23.Site diagram or additional well details:
8,For GeoprobeA[)pr 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 GW-1 is needed. Indicate TOTAL NUMBER of drilled.- construction details. You may also attach additional pages if necessary.
9-Total Well depth below land surface: NANLTz&-0VAt-j=0-AS-
For multiple vV0118 list all depffi,ifaiiieen,(er---,P-17-3@-2-oo•—.ud 2—@,00.) ON 24a.EU_Vl X.fi,: Submit this form within 30 days of Completion of 11
10-Static water level below top of casing: construction to the following. we
0'�-Ier level is above .Ig.ure (ft.) Division Of Water Resources,Information Processing Unit,
!II-Borehojediameter. 6 1617 Mail Service Cen'
On.) ter,Raleigh,NC 27699-1617
24b. In
jection In additi
12*Well construction method: ROTARY abo &pALeelve,also submit one ' on to sending the form to the address in 24a
("e-auger,rotary,cable,direct push,etcJ copy of this form within 30 days of completion of well
construction to die following:
FOR WATER SUPPLY WELLS
Division Of Water Resource,,Underground Injection Control program,
13s.Yield(gpja) Method of test: AIR ROTARY 1636 Mail Service Center,Raleigh,NC 27699-1636
-------- 24c.1111111% Water #Jnj!cto t
nj a:
13b.Disinfection type: HTH the For � M U& In addition to sending the form to
-� Amount: '?ao 'ddress(es) above, also submit one'copy of this
completion Of well construction to th I . form within 30 days of
where constructed. e county health department of the county
Form OW-1 North Carolina POPBrtmont of Environmental Quality-Division ofWator Resources