GW1-2022-09988_Well Construction - GW1_20221104

- W�:LL CONSTRUCTION RECORD !c'w ��
For IIsr Only: +Print Porn�--
1.Well Contractor InYormation: brtemel I
Christopher Wachter
Well COnm_._N.._ 1A WATER ZOEIES
PROM TO DyI
4448A "• "t. Y0 LlS 2
NC Wall Coneactor Co,tifintion Number ft. t4
Cummings Developments, Inc. 1E.OUTER CASING(for MWfi•eo$ed weft$ OR LINER fir.,
FROM TO DIAMETER TWCILVE96 MATERIAL Company Namn ♦i ft. (t
g in. PVC
2,well Construction Permit#: Z Z- O Z -W IA INNER CASING OR TUBING eotherm cimd400
we
Lill all app@rahle i/commmrim,pe Jk(Lr•UM,CoanN.STak.Ymfann,e1r✓ FROM 2 TO DIAMETER TEICKNESS MATERIAL
3,Well Use(check wen use): n. In.
R
Water SupptyWell: ft. In.
17.SCBEEp
Agricultural ❑Municipal/Public FROM TO DIAetEaAss aLOT'SIEE THICKNESS MATERIAL
Geothermal(Heating/Coolmg Supply) ®Residential Water Supply 1 ( S sin le) tt' tt. as.
IndustriaVCommercial tt. tt, In.
ORaddential Wen,Supply(shared)
I ' tioD IS.GROUT
Non-Water Supply Well: TO MATERrAL MaTNOD9AMovNr
Monitoring a tt• A h pates pour
Wection Well: Recovery ft. R.
Aquifer Recharge �Greundwatcr Remediation D. t6
Aquifer TestStor and Recovery ®Salinity Barrier 19.SAND/CAAVBT.
Test PACK )g
Aquifer FROM TO MA EMPWCEMOMMETHOD
® mrwater Drainage tt, ft.Expel•immtal Techgol Sto
CRY 13Subsidence Control
Geothermal(Closed Loop) D• tt.
OTmcer 20.DR GLOO anaeh
Geothermal Heetin Coolin Radom) Othet•(exPlain undel•#21 Remerka FROM •ro addmonal$beat#itDasrgtPTlaNtwwlIr n,m,m,,,,Frru, r.m sbe.$nu
4.Date Well(s)Completed: © ft.
well M# at.
Sa.Well Location: 2
rt.
it. Is,
;-� Funky Was(if appliceble) It. H.
AdiEw,Coo and Sip N(•
ry tt. rt.
t ss35?aa4s� 21•RIC RRS
Cauoty Parcel Identification No.(PIN)
Sb.Latitude mud longitude in degrees/miamos(secoada or decimal degrees:
WINCH field,am btAmS is sunicim0
Il o r)S. L/Sk N _._2{ " 33 . 3L Cerflnca
w fr�b
6.D(sre)the well(s)OP"Crament or ❑Temporary aturo Rod Wall Conhaabr
DW
7.Is this a repair to aD existing well: s Ening Nis form,I herehv crellfy that the well(..,)was(were)emtso'uued h,acrordanre
/Ifthls is a repuin f111 our known,vr11 counnvaao®Yet Or rruruRun n®plain,hn name.,nflhe rovY vJ rh CrAr nrdr�Oh�u pro vided M U e a(/0200 Well Consfru<ltan 57m,mrds and/dal a
repair„uder#21 remarks section or an the backoflhisfa,n.
8.For Geo robe/DPT or Closed-Loop 23.Site diagram or additional well details:
F Loop GeatherrAW Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMB ofwellER s
w
drilled: construction details. You may also attach additional pages ifnecessary.
9,Total well depth below land surface: 2�o SUBMITTAL INSTRUCTIONS
CTIONS
For mulliple arlk list s/Idepths/tediBerent(eranrp/e-3@200'm,d?@100') (R•) 24a• For AR Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static wafer level below top of easing:N wotrr level ix o/wvr _ j (ft.) Division of Water Resources,Information Processing Unit
casinE,rue"t"
I I.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699.1617
(In.) 24b.For Injection W Wells; in addition m sending the form to the lesion f well
12.Well construction method: Rotary above,also submit One copy of this form within 30 days of completion of weii
(i.e.auger,emery,cable,dnect Push,etc.) conahuctimt to the following:
[13b.D:j6dnfeCfiOR
R SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1 1636 Mail Service Center,Raleigh,NC 27699-1636
tm) / Method of teat: Air Rotary 24e. For ware
' 1 I i tlon Welts! In addition to•ending the form to
type. HTH the address(es) above• also submit one copy of this form within 30 days of
Amount: '� completion of well construction to the county health department of the county
MM.consuucted.
Fmm GWA Nonb Cnrolirm Depamnent of&rvironnmmal Quality-Division of Wnter RcsourccT
Revised 2.22-2016