GW1-2021-01622_Well Construction - GW1_20210401

For Internal Ilse Only:
B M- CQBT--RUCn0—N& JGW-11*
I.Well Contractor Information:
Christopher Wachter 1 14,WATER an—S
WOU
Well Contractor Nwe mom MO N
K*we"canctorcertification NWAU IS.OUTER CASM(lbr muld-cosed wdb)OR UM Of ndkLbkj
Cummings Developments, Inc. '11tom I TO I OMMUR I THICKKM MATERIAL
couipaity Name lb
& 1/0 R. 16&Z In- 1 .188 G.ftel
16.IMER QAMG OR TUMG(mllinval dwed-loon)
2.Well Construction Permit#. t 2- LOG U0 Q-L:) rRoaa To P1AN9M I VMCWP---
1�. an,
3.Well Use(ch"Li-wa use);
&
dater Supply Well: 17. N
Pam TO I DIAMTER I ffi"rsHM- I Inn nine I MAMMIAL
DAgricuitursi C)Municipal/Public R. &
Doeodicrow(Heatimcoouns supply) Skesidentiw water supply(single) %
131ndustriall/Commerei8i
den!
M NATFRIA
?400-water tiip—ly Will: V ft- 20 fL Port Cement Pour
3—monitoring %
Injection—wen.
3Aquitbr Recharge 03oroundwater Remediation (L (L
19.P N2MNPq&EACK tif MN910—mbb)aquifer Storage and Recovery DSalinitv Banier
twit, LffitonawaterDrainage
-- -- ---
— I'
ft. t
cicor� 'Techowagy Subsidence Control
Owthenual(Closed Loop) DTMM 7ft fw"Iwh -LOGlata cgldiffmaftff
o 00ther(expltin under#21 Remarks FROM Iftere"ard
4.DAte Well(Q)Completed: woo ID# 9L IL
52.Wen Location- IZ? ft- MT 40ac,
-CuML"t ±w-at'-5- ft. ft
Facility/Owner ra Facility IN(if applicable) D. IL
l'bysical Address,City,and Zip ft. &
—3-3-k Lo,5
COUVIV Pence!Identification No.(PIN)
5b.Latitude and longitude In degreeelminutes/wAonds or decimal degr 11160M'3t
(if well field,one!among is yffi /
cient) 22.Certification- V­
-356 S7r -716 a 6,Qj2
—W ZI
6-i4am)100 we"(S)WIaemm"Cut or UTemporary st DM
Ifty?S I nfiam,I hereby cinify that the well(s)ivat liva4 constructed in accomimca
7-Is this a repair to an V"ug wen: E]Yes or MNo with 15A KUX'02C'.0100 or 15A A-AV02C.0200 Wdl Construction Syntadungs and that a
YINT&a repair,fill out known well cOnStrudlon Wonnaflan mid explidn the nalm ofthe -PY afthiv record lies been provided to the well aww
repair undera2l remarks section or an the hackoplisfolm. 2&Site diagram or additional well details:
8.For GeoprobaMPT or Geothermal Wells having the same You may use the back of this pop to provide additional well she details or well
arbi
9.Told well depth below land surface:
l'brinumpa waits im all mpas y aormnt(womIge-3@209,toul 2@ 100) —Pt-) ?An.IQLAUNJO Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of easing: - ?H Division of Water Resources,information processing Unft,
if water level is above casing use 1617 Mail Service rpnovr.22!etnah,!plc
tan.) 24b. or line In addition to sending the fwtnto the address, ,#4a
IL Well construction method.. Roca Wma,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction 10 the following.
FOWWATER SUPPLY WELLS ONLY- Division of Water Pesourceg;Underground injection Control Program,
1636 Meg Service'Center,Raleigh,Nc 27699.1616
ISa.Yldd(gpm)...,.®L Method of t.#,Air Rotary 24t.For Wrtiwr M 11A
the a .
s
13b.Disinfection lype.- HTH addresses) above, 8180 s it)one-copy of this form within 30 days of
Amount: 2. rpletioxi of M.T41 construction to the coualy,heft department of the county
where constructed.
Form GW_l North Carolina Department Of 11111AamMMI Quality-Division of Water Ramroaa Revised 2-22.2M 1;
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