GW1-2021-00730_Well Construction - GW1_20210401

irror internal Use Only:
I.wail Contraddor Information:
Chdoopher Wachter I& AT ZO S
FRolrt To
Well Contractor Name
IL
MC Well CoatractorCahfieationNumber 11 11flitR
Cummings Developments, Inc. =ON To DtAiaicult I TNiCIiTT� aSATElmAL
company Neale +9 6`:5Ja3
lda GOR`l`Y>RIt�� tom:
2.Well Conseraedon permit 0. M A -319(� Z( AMMB Twe M ees r_
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Water Supply ell
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t?ON _ To MATMITAL ERSPLA TJIE9.t &;�ttv1® hT Q 20 fe. poetCement Pour
:chalge {GroundwaterRemediationrage and RetusverySalioity Batrier 149 SGRA'lEe,t?AtD a
P'1 e41
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&jStarmwater Drainage ft,USubsidenceConuol ft #fl.ermal(Closed loop) DTraeerrmal(Heatin Cool' Retain Other(explain under#21 Relrlartcs TO D ° °Q
4.Dalte Wdl(ts)Cam : 2 MAIM
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Stu.won Location:
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Facilitylowner7duto Facility 1Dli(Va"licable) t P"
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t'a lIdentiti�tio,No.(FIN) Processing Uni
osc:�on
Sb.Latitude and longitude In degreediniuutedmondo or deciusel degrees: QV"J P
(ifwell field,an hattlong is suf acal) 22.Cerdffisad
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a.isiare)the welt(s)' Permanent or d emporary Certified Well Contractor Date
11y sigPthng this firm.I heMAY CM-6 that the weftft)was(were)constructed in accordance
7.Is 41119 0 repir to an adsdng wen: Oyu or lino with 15A N[.AC 02C.0100 or ISA A AC 02C.0200 Wdl C.onsttuction&anduaels and that a
Oh"/a a repair,fill-it/a—we/leonstruction ttpormation and explain the tratrtns ofilte conYafthts mcmd has been pt»uhWto the nail owner
pairunder a21-mar&canton or on the hm*gfthet farm.
23.Site diagram or additional wr¢ll detolls:
tl.For taeoprobe/I PT or Closed-Loop Geothermal Wells haft ilia saute You may use the bade of this page to provide additional-veil site details or well
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Total welE depth blew land surface» M. &y All_�oHLc: Submit this form within 30 days of completion of email
hormultiple wens list all depths ifd=11 fezoatple-3 =oo.and2�tAx
( �, M"Is� am to the following
I fl Stud%water below tap of casfiing;_ +i (6.) ID1*10n of Water Rmorcxs,Imtbrmadon P ilrg Unk
ljlrater Level taahove aastrtg:use"�-
,m 1617 Mail Servim.'repter.Lualetuh.ri "�`Yw-t59y
Em flulacelon Malls: In addition to sending the form.to the addle ss•in 24a
IL Well.eonstruedon Rotary above,also submit one copy of this form within 30 days of campietion of well
0A.auger,rotary.cable.diem push,etc.) conshruotion to the following:
FOR WATER & WELLS 0 ��` Division of Water purses;Underg sand Injection Control m,
106 Man Service center,1weigh,RTC 2789-16 M
M Yield WHO) / _ McMod ortrrnte Air Rotary 24e,goer Wrtrr Run-. A B:r:,..
HTH5-� the address(cs) above, also submit+one-copy of this form within 30 days of
fl3lb.Disinfection type: Amount: � cotiVation of uuell rAnstreact on to,tt coway health deparnbM of the county
where constructed.
Fonn OW-1 Nonh Cgrolina Department of finvirflnmeeW Quality-Division of Water Resource$ n,.;.n