GW1-2022-10095_Well Construction - GW1_20221104

• WELL C INSTRUCTION RECORD
GW=1 For internal ae my Print Porn
L Well Contractor Information:
CHRISTOPHER WATCHER
Wall Contractor Neme It WAT 7AIlYEB
4448A PROM TO DESCRIPTION
NC
(PO R Gz it
Well C" actor Conlaelal.Number �-
CUMMINGS DEVELOPMENTS , INC R
CumpunY Nume FROM R 7p LNG MUM- ld wens ORLINER ffa
DIAMETER THICKNESS cable
_•Well CO 't h• R MATERIAL
IaefPOCtiOn permit#:_ '(� �� A '� '7 6 518 In• .7ae
LWon,app)Buble,vel)ranrlrar/lonju, C. 7&INNER GOY•f•DBINC G.STEEL
p r UIC C PROM .Ihermal dated.100
3•WUi Use(check well use); 0%Smra,padun— rr,r�!r.� DUMETeR Tu1cxNEss R. R io, MATERIAL
Water suppy Well: rt. ft
in.
AgI•icultutal 17.8CREPAy
Geothermal H ®MunicipaUpublic �nM TO DIAMMR SLOTSII'E THICKNESS
( eatit'g/Cooling supply) ®Residential Water Su 1 R.
IndushiaVC PP Y(single) R' fR. MnrEa1AL ommercial
Irri•,Ilan Residential Water Supply(Shared) R. n' in•
Non-Witer supply Well: I&OROUT
FROM
Monita[Ir'g 0 IL 20 h. MATERIAL EMPLACEM&NTMET HOD is AMOUNr
11QlMon ell: Recovery PORT.CEMENT POUR
Agnifcr Recharge IL ft
Aquifer Storage and Recovery DGmundwater Ronlodittion R• ft
Aquifer Test 08aliniry Barrier v SANp/GgAVEL PACT(
OgmnlrWater Drainage IRtom TO • le
Experimental Technology ft. MATERIAL EMPWCEM
Q9ubsidence Control R ENTMErnon
Geothermal(Closed Loop) R
Misterft.Geothermal satin Conlin Return) Mister
ex OG afhh addltlorW aheefa IfReeeua
4•Date )
(explain under R°O°t ro
c
W,e DESCR'P1'ION color ho, wlrrack r n rtr,l
il(s)Completed: `"Z Z Well ID# � It, ft.
Sa,Well Location._ / 1 ��� � it" 22. ft
•ily�-v1-'+�Ln� '" 2 R. +� R
Pudt13'/OwnOr Nemo R. r
(L
Facility lDa(ifappilcehlo) Q R• r,•j,
�l s IL
Ph i
2 V ft. IL '
County —teals�8i✓, =1.YP2M,,pgg r�"^' i)r:p
Pa1ecl Idawlk I.No.(PIN) .46.Latitude and longitude Bn d
(if well Rcld,one let/lo egrees/sai utea/second,or ng is suFfeicnt) decimal degree,:
0
c aI , 07& N 17° �23 22.E e�rr,ar
6.Ware)the well(sOpe
rmanent or ®Temporary /',� 'Z Z taro ofcart(gad Wall Connector
7.is this a repair o an existing well; Dam
U/his it a repah:n0atll coma,well ronrnncl1nn iV umllor a®NOuin Uir nuMry o/'/he ro .rignbrg Ihirtwin,I Aerebv cep/fy thal du•well u'hb ISI env,02C.0/00 or IJd NCAC 02C.020p well C rr fypn'ionl S/ai dwyr and lmlua
repair under#21"'a"ekrm9lon ar on the bark ofr/t/xfonn.
PY Irhlr record has heart pvv/ded ro du'wxll owner.8.Far GeoprobODPT or Closed-Lau 23.Site diagram or additional well details:
constmcuan,only I GW-1 is needed, 1 GCOe TOT l Wells having the same You nlay use the back of this page to provide additional well site details or well
drilled: Indicate TOTAL NUMBER of wells construction details. You'nay also attach additional pages if necessary.
9•Total well depth below land surface: �4 fJ HIIBMITTAL INSTRUCT
ONS
For mu/hple wills llrl all depths ifd%fferenr jeramp/r-3 [�a00'orrd-®I00'1 (R') 24a. 0 1 s: Submit this farm within 30 days
of completion of well
10.Statle water level below rap of caring: `j construction to the following:(f wnMr level U above cwsing,,ue'•+"
(D') Division of Water Resource&,Information processing Unit,
11'Borehole diameter: s 1617 Mail Service Center,Raleigh,NC 27699-1617
12,Well construction method: ROTARY 24b.For Infection Wells.
. In addition to sending the form to the address
in 24.
(i.e.eager,mmig cable,Jircet purh,earl above,slap submit one copy of this form within 30 days of completion of well
construction to the following:FOR WATER SUPPLY WPs s e
ONLY: Divisloo of Water Resources,Underground Injection Control program,
13a.Yield(gpm) 1636 Mail Servile Center,Method of test: AIR ROTARY Raleigh,NC27699-1636
136.Disinfection type: F177'I �-- 24e-Fnr Wafer Suooly&Intec'on W In addition to sending the form to
Amount: �QL the addressee) above, also submit one copy of this f
completion of well construction
to the coon oral within 30 days of
Form OW-1 - whew constructed. county health department of the county
Nonh Cmnlina Dcpann'cal ofEnvironnres"d Quality-Divirlaa of Water Resoums,