GW1-2022-09970_Well Construction - GW1_20221104

WELL CONSTRUCTION
RE OR w I,
L Well Contractor information: For In[orn 11 Use Only: Print Forn
CHRISTOPHER WATCHER
Well Contactor Name 4.WAT PAINFS
4448A aROM TO DF9C1 '[ON
R. S
NC well C R.
onnaoror CnUfieadon Numbor
CUMMINGS DEVELOPMENTS,INC b rL
1&OUTER CASING formultQu ra xaDs OR LINER If.
Campuny Nume FROM TO e DIAMETER TNICKNeaS
2•Well Comtruction Permit#; II \ f� 't R' R. MATERIAL
—L lit 0 IrS I&DINER aSr8 In• .leg
Liera//appyrable Curl]rons(prr((on re CAEING OR TUBING O•STEEL
Ui c C unry,SArm,Par/artrr, pRor4 TO eothermI I clawed-low
3,Well Use(check well use): "/r•) B. DIAMETER TNICKNESS
R. in MATERIAL
Water Supply Well: R.
R.Agricultural 17.SCREEN in.
Geothermal(Heating/Coolin Su 13MunicipaVPublic FROM
S PPIY) QResiden0al Water Supply R• °/MtaTlta aLorslas THICKNISS 7ndushiaVC PPY(�ingle) R• 1p. M1IA'1'ERNL
ommercial
kri lion EIRcsiddntial Water supply R• R.
Non-Water Supply Pp Y(shared) ro•
PP Y Well: ta.cRolrr
Monitoring FROM TO MATERIAL
a ft. EMPLACEM&yT METHOD&AMOUNT
ion all. AeCOVery, Ya R' PORT'CEMENT POUR
Aquifer ft. R.
Aquifer Storage and Recovery DGroundwatcr Remediation R• tL
Aquifer Test Debility Barrier 19.SAND/GRAYEL PACM a
0stonnwater Drainage FROM TO rabic
Experimental Technology ft. MRLABMENTME Subsidence Control ft. AT6 L GMPWC THUD
G eomerrrlal(Closed Loop) R
Geothermal Heatin Tracer ft•
Ae
Coot mm) . Omer• eElain under#21 Remar 21111 LINGLO aaachaddltionalsbeea if seen"
.
4,DateWeB(s)Completed: Remarks) FROM TO' DESCRIPTION wIw haN eelYraea- - R• rte•i
5a,Wall Location: LbbS Z Wdl ID# R I J
R. 2 To R.
IL
r..waavremo R h
Facimyw#(Ifoppumbic) R. R.
Physics]Addres,Chi Said �\ f. ft. -
a
R.
County ' Sl.REMARRS
5b.LatitudePuari identification No.(PIN)
and longitude su i. degrees/n hung,dsecands or declmd
(iPwoll field,ono laYlong is aufi;Cmm)
C1 / degrees:
_��FoO I • (p I0 1 p---W 22.CertiPu
N ' oil • G Z
manent a
6.Is(are)the well(s)4MPer 1 D
or �Temporaty 7.Is this are Si�et1f0 fled Well Commi
pair Po en exiatln Jo Data
/flhrY CearePahtJ!/(au/pngar ive/gonalUiucNoO esrmlo1and��uin rAv nahnr ofl6e caPY 114 Nrer702C,ijai 15.4Nided ICO2C 020rer.
xdlh rArrNCAC 01C.0 00 orv/JA C CIOdC.01/00 W gsCo slnrclionr9ly da and tlral a
repair wrdrr#1/remarke rec•Ilon ar ou lute back oJlhlsform. arnmlaare
11 For Geopro only
I G or Closed LOU Ceother 23,Site diagram or additional well details:
collect; ioq onl 1 GW- mar NU having the same YOU may use the back of this page[o provide additional well site details or well
drilled: Y I is needed• Indicate TOTAL NUMBER of wails conshuction details. You May
9•Total well depth blow land surface: y also attach additional pages if necessary.
Far muldP/ewellr l0l all drplhr lfd�rrwn licmu1����(PL) ar S
P Q100 mrdqd®!00') 24a. 110i;—: Submit this form within 30 daysof
to*Statie water level below top of casing: 3 / construction to the following:
!lwnmr/eve/k shove cwlnq Completion of well
a are^a• <ft•) Division Of Water Resources,Information Processin
11.Borehok:diameror: s
(in.) 1617 Mall Service Center,Raleigh,NC 27699.1617 nit,
12.Wall (in.)
method: ROTARY 24b.For Injillition Wall,: In addition to s<ndirrg the form to the ad
(i.c,auger,unary,cable,direct pwh, - above, also submit one co of dress in 14a
constuction to the following mts form within 30 days of completion of well
FOR WATER SUPPLY WELLS ONLY:
Division of Water Rea turcea,Underground Injection Control 1636 Mail Service C Program,
136.Didnfe
13a.Yield(gpin)�— enter,
dion Method of test: AIR ROTARY Raleigh,NC 27699-1636
type. HTH 24c• or Water Suooly&Iniec' n W
��� Amount: ZSo Z, the addrese(ea) above, also submit one coy oaddition
tlhisrortron sending me foal to
completion of well conshnetion to me coon Y within 30 days of
Foam Gw-I where constructed. ty health deportment of the county
Non"Colt""'Department ofiinvimummmml Quality-Division of Water Resoures