GW1-2021-02063_Well Construction - GW1_20210620

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1.Well Contractor Inforased": I I
Christopher Wachter r 14.WATER ZONES
FROM TO DESCRTMON
Well Contractor Name �•
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NC Well Contractor Catificatial Number 15.OUTER CASING for multi-eased wells OR LINER s bk
Cummings Developments, Inc. FROM TO DIAMER TTIICKNM ET MATERIAL
+1 ft. ft. 1 6 518 in' .188
Company Name 16.INNER CASING OR TUBING thermal dosed-leo
2.Well Construction Permit#: , _-- _ FROM I TO DIAMETER I T HICIUMS I MATERIAL
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Water Supply Well: I .SCREEN
FROM TO DIAMBTRR SLAT SLZS S38 MATERIAL
AgriculturalMunicipal/Public ft. ft, In•
Geothermal(Heating/Cooling Supply) Qkesidential Water Supply(single) ft. ft.
lndusstrial/Commercinl S lPPCirlratia!Watrr C::tanly fibarprPP -- --
k__p Irrigation l( FIRM TO I MATERIAL �_EMPLACEMMr M_ETWM A AMOUNT I
Iwlrrralel oupply rveu: "' Lu "' tort Uement wour
:3Monitoring ORecovery ft. ft-
Injection well: ft. ft. —
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK dx ble
' Aquifer Storage and Recovery Salinity Barrier cwn u +�. M
unLlCl lluculm I tawluwgy k_JJUUSIUGIIGe l,Unl1U1
Geothermal(Closed Loop) 13Traccr 20.DRILLING LOG attach additional sheets if
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Geothermal estin ooling Return) Other FROM TO DU lain under#21 Remarks) ft ' fL N sa7troek is she,ate
4.Date Well t
s)Completed: �✓ Well ID# ft• ft-
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52.Well Location:
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ft. ft.
Facility Naas Facitity ID#(if applicable) k ft.
Physical Addresses�itv.and Zip ff ft.
CAS .,r.
County Parcel identification No.(PIN)
5L Latitude and longitude in degrees/minutes/seconds or decimal degrm:
(if well field,one lat/long is suffician) 1 22.Certifi
3
v.rir;,uy sus-xelyart-�p-tarauCul ur Lj a terupurxry
ity.vpling ihi.t fuim, i hc,,4.y ct:tiy`y dfui NrC weii(s)was(were)constructed m a4cortionce
7.Is this a repair to an existing well: QYes or E)No with 15A NCAC 02C.0100 or 15A N'CAC 01C.0100 well Conrlr uction titandards and that a
(f this LT a nepoir,fill our bw3m wmU aaasrrufias wfannariwr and explam Ube r awv y faw ropy ofrhis record har been provided to the well owner.
repair wtder 11 rewarb sedhm or on the hadr ofihlrJ6rm. 23•Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
Cnnstructinn.defn;k Ynn mm'.n!cn:tttnch wid-finny.!n
urlllt:ti: ar!awr•sa^r•c, rt►'{�T•nii!"1rfAlate
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mahiple wells list all depths If d!f'rrem(example-3_ OD'and 1fg)1(xy) 'Idt t�.i�
1 c�"'SS4'ittCtit'fn to titt
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above mving use"•" 1617.Mail Service Center,Raleigh,NC 27699-1617
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nl.rn.n ntcn c..l,m•} n»a �.nrj n1' thtc tnrm aznfh.» ill C!--of Cl nlnn rtln:l f11 WPII
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12.Well construction method: construction to the following:
(i.e.auger,rotary,treble,direct push,etc.)
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
. Air Rotary up-Water SLnDty R iniection Well,.: In audition to sending the form to
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J where constructed.
Form GW-I North Carolina Department of Fmironmenta!Quality-Division of Water Resources Revised 2-22-2016