GW1-2022-06259_Well Construction - GW1_20220628

WELL COIOT�TRITC rION RECOfltA(OW H Pri fForrr
t� � For Irltemal Use Only: --"Well Contractor InfePm9tlon:
Christopher Wachter
Well CoutraetorNamo 14..WATERZONES I -
4448A FROM TO DESCRIPTION
`rY 2T • '71 tr.
NC WeR Contractor Cwti6catian Number 61r ft' 01 ft '
Cummings!Developments; Inc. YS.OUTER CASING
FROM TO DIAMETER TH1CRMF- MATERIAL
Company Name +1 %
2.Well Construction Permit#: ZO Z7-y O Dd 16:llVNERCASING IDR— PVC ING f"ectiierwl eloaed-lo0 _
List all appurableiwent'anshztcllon pernlfGr�s:fAC,County,SIafSYa nre,etr� FROM TO
TEICi4UE83 MATERIAL
3.Well Use(check well use): In.
` In.
Water Supply Well: fi' ft ht.
Agticultural 1Z'SCREEN.
1311unicipaUPublic FROM TO DIAMETER BLOTBIZE THiCKNEM - Iy JYRr PAY, }
(leotheratal(Heating/Cooling Supply) JaResidential Water Su I (single) R. a. �
IndusniaYCommercial PP Y( g ft.
DResidential tn.
Water Supply(shared)
Irri tion 18..GR0UT..
Non-water supply Well: FROM To MnTER:AL z Ymrl ACEMBDrr mErnoD&AdroulVT
Monitoring 0 R. 20 Portcement Pour
Lt,(ectlon ell: Recovery ft
tI•.
Aquifer Recharge ®GroundwaterRcmediation t. n
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACIE ,a'7ic le.u=
Aquifer Test FROMExPer 70 MAIEIUAL EMPLACEMENTMETHOD
�Stormwater Drainage ft.
Geothermal l Technology 13Subsidence,Control
Geothermal(Closed Loop) DTracer n• ft.
Geothermal He Cooling Return) Other(explain under#21 Remarks) 20 DRYLLYNG Lo(i attach°daido4wl�hceta if cecesca
FROM TO DESCRIPTION(colcr hs,dn soIDracic
�ft. ffi size.etc.!:
4.Date Well(s)Completed: '/�O'2 z Well ID# ,I
52.Well Location: ft. )
ML g•
FacVty/Ot/nv�narNamo Facility ID#(ifappllcablo) ft. O,
MINI
(fix It1 �r-i 1 ft. ft
Physical AddM city-,cow.. f
Zipft. ft •••,:U �J lJrsli
21 REA7ARI{S: ... o L
County Fated ldentilication No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wall field,on la1/long is sunicient)
_D N 79 ��.. JL 22.Certifica on•
l&-z,I
6.Is(are)the well(Alffiment or Temporary Sign a of Corti cd Woll Contractor
Date
7.Is this a repadK to an existing well: 13Yes or MNo B'slgniug lids fear,/here4v ccj100 or IS YiY Thal the wells)was(were)eotrsVaded hi accordance
Phis is a repaii fill ont known lyeneonshuclion lglararallon and explahe the nature oflhe c Pl'J rh reAcord has0herat provided�o a xr'uorAC �a Well Cortalruetlon Standards and that a
repairuuder#21 reinarkssedion Oren tha;backoftltlsfornl.
it.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You
Site diagrams1 or k o H�al l toro additional well site details or well
construction,only 1 OW-1 is needed.;Indicate TOTAL NUMBER of wells You may page provide.
drilled• construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: /2.® SUBMITTAL INSTAL=LO S
Formultiple Welk llsta//depths(/aliffaraat;(exanlp/e-3@300'aid3Q1009 ( ) 24a'Igor All Wells: Submit this form within 30 days of completion of well
construction to the following:
f Stake water level below top of casing:_ D� ) Division of Water Resources,Information Processing Unit,
If water level is above casln�use °+" (ft.
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699.1617
Gn') 24b. or In ection cable Weis:
12.We In addition to sending the form to the address in 24a
(i.e.auger,Well Rotary above,also submit one copy of this forin within 30 days of completion of well
nary; ,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,UtidoIrground Injection Control Program,
�• 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test'Air Rotary
24c.1For Wato► Sunni.a r..l etloe MIells: In addition to sending the form to .
13b.Disinfecfion4ype: HTH Amount: (� the addresses) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the oormty
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22 2016 -