GW1-2021-00742_Well Construction - GW1_20210401

WELL��1 �T BI I � $ For Internal Use Only:
1.well t oaft dor 9nfiurniaBon:
�l n�o her Wachter 14.WATIR ZONES
029CATP9'M
Well Contractor Name tt So ,
f
htC WoN Cotitracict7etificstion Number t
"1S. BTFER CASIN(8'fos
Cummings' evelopment�s Inc. mom ; � D � rxt �►
con perry l�na, +1 E R. & 6 5/8 In. .1E(Eli C.St"I
I6. Ct�iNG tAR 1Ptt3 �¢radiAl
2.Well Contraction Permit#: 31( W E LV-.'Z 1 F�1"� �; TQ nlidt o •�
t:,r.•.tt, .,t:. �.r>. _ _. � 'rrrrt'.'��S AE-�__A_�_•'3m^E -
• . •• ••_ •u ,�iy'i •i w• Y1141tY4:.IA1,.) A..
31.Well,Use teback well use)..
01ndustriWCommim
ater supply @dell: r9.'ilL' 1N
Agricultural �Manlcipal/Publie fe. carom 'rnttc 0" �eratarA
Geotitemlal hL
meati4cooling supply) Midentle!
Residential Water Supply(single)
ial R`•�l Water f:tmnkt fct arR,t\
an on
-Water v Wil.fio •
zo aanr e I
_
Esesnesvai e71oD-a AMOUA-9
20
vMoni Reary Obit Cement Pour
ln4iq— oA etl: R•
uifer Rerhip 00roundwater Remediation
uifer Storage and Recovery OSalinity Barrier !i� AIDt�NA PACE a
~U.Hui',"art: �Stmmwataa'Drainage
raeAtaTT'eoliftolafw -Stlbsidimm Control f!: �
Geothermal(Closed Leop) OTracee Ztt otata l elvB add:
Geothermal(H 1' Retitm Other(ex faits under#2!Remarks nr art M "Wnch J.bw.WAs ei
C Date Waff(a)completed:j Wen I" EL ! fL
St.Well lLocatlon:
�-
Facility/OartterName FecilitylDH(ifapplicable) 06
Pbyaical Address•City.and Zip &
Parcel Identification No.(PR AnlarMal,F
1 c 0n
ft Ladtade and longitude in degradmimitealseeonda or decittim!degrees: V
(if wall field,one tatitong is suffieient)
ZIhisfim
or [},�Temparary i Contractor Dme?.1s reby ven#y that the way(V war(were)onmlructed in occonfi m.e repair t0 a6t lstiAg well: byes Ora'
with 15A NC:AC 02C.0100 or 15A At(:AC 02C.0200 Walt Constructiwr Stmulaerls and that a
ff1his is a P*WP,fill oil Anown well conrtr ualon h{Wunimr and eiplain the nm=ofths copyofthis r o;dho been provided to the welf otyuer.
r mt3 under 821 mmwb sociti+ur to on the hii*eth ifo m,
4 *.P-•' 331.Site diagram or additdouni well detalis:
>t.dFor d�etiprohe/19tP7'Or,�lose�g gop Geothermal Wells ha the You may use the back of this to�° same page provide additional weft site details or well
��12t_tl+tlf:t�1N i�!?�:!:i:tt^^rT-rt' T:rTr•,tt.:Tv't^.•�: err.vs err rV-ram
ei / �t% 11gi'3$�S'l"i��rNi�u'"i'➢ki[?f"t'r�'ACtt�a'
T'otal�wt,depthlelow tmtid surface: (R•D 1%armult►ple jW18!/srcJjaaptke#-,k£e wt(amnrpte-j200•mrd2{�lM fir : Submit this form within 30 days of completion of well
/ construction to the following:
ILSttib weter level below top of caaf�:_ D!®isfoa of Water Rsstra
i'lfwatar Tavel is abate ozslrr�use tees,inforumtion Pmeessirg Unit,
'r cg ien p L 1i617 man Servi p renter,teal ,1�d2'9`1iS9m_t.<.T�
---+ •..�. a s t y, 24b addition to sending the form.to the addtess•in 24a
12-W4M CO=truetlon • P e , '.3 above,also submit one copy of this form within 30 days of completion of well
0-auger,rotary,sable,di M,push,cn; — construction to thMliowing:
f'
1Dlvision FOR�^JA•11;R of Water 1esour S61f'IP9 i�t. ,QIRiL,�: : tom,Underground Injection Control haMm,
tSa.Meld f t'7 ,: w 1636 R(deil Service Center,Rzfeigh,MC 24619-16M
�) •" t Ilod of teo-•Air Ro8�r24 a�gge er aut t,. o _
.G t•. rrE• F �.f l4w;t 1' Tsd{m14....,GJ,nS:... F.- ••
13b.Disfufection El a,li7H .6he address(es) above, also submit one copy of this form within 30 days of
E: imltiptetiom of VAR:construction�the oo health
F utTty department of the county
,.,� a., where constructed.
Form OW-1a Department of fiaveeo3smentat
i North Carolina Quality-Division of Wetar Recounas