GW1-2022-07592_Well Construction - GW1_20220817

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1.Well Contractor Infor For Internal Use Only: Font Forn
• ration:
CHRISTOPHER WATCHER
Well Contractor Name 14:WATER ZONES'
4448A PROM TO
R. DESCRIp1•lON
NC.Well Coatraotor Cortlficatian Number
CUMMINGS DEVELOPMENTS, INC 1t
18.'OLT1ING`Poe'molft:ceeedmill ' R ifi "D
Company Nam OR':L1NE e FROM TO
DIAMETER 77tICKNESa MATERIAL
2.Well construction Permit +1 ft.: � e� In' .teB
Ltar a!l applkablr the/I consertrrt6on Permits LL Z'Z etc.) 76'�NER Cgg1NG 0R_T.UBINCr O EM
P County State.t'arlanEr, t�oM To aft It 3.Well Use(check well use): R• IL, lo. CKNEss MATERIAL
Water SUPIX Well: II• LL
Agricultural 17.SGREEN:;
OM
Geothermal(HeadMunicipal/Public FR Asr -
ng/CoolingSupply) LT E7ER sLOTSIze
esidential Water Supply(single) DI In gas ^ MATERI AL
IndusniaUCornmential ential Water Supply(shared)
fr.
Irri ion Resid PP Y( R• !in.
Nlon-Water Su 18: ROu r
PP1Y Well: FROM 40
Monitoring O ft. MATERIAL 20 R' EMPLACEMPNTME?1On&AMOUNT
�Ilcetion eJJ; Recovery PCRT.CEMENT POUR
Aquifer Recharge ft. f1'
Aquifer Storage and Recovery Groundwater Romodiation II• R
Aquifer TestSalinity Berrien 49:SA
FROM ND/GRAVEL+PACK
p� a-li- 1 s
Experlmentol Techoology 13stormwater Dt inage MATERIAL "' *'
R. & EMPLACEMpNTMErHDo
Geothermal(Closed Loup) Subsidence Control
Tracer R' IL
Geothermal ea Cool' ?A.DRILLING LOG
Returmr) Other ex lain under#21 Remarks ON! To edaeh tiddltlun`al ahaetadtne -
DESCRu0noN color he eoNroek n etc.►
"ate Wells)Completed: '2 -�iz n•
� Well IIIID#
So.Won Location: R' �2 1L
` C
c Q L a� _ ►'_. R• ft.
Fatuity/pWyor II• IL,
Fscruty 1D#(ifepPUcable)
UND l�t l l►� 06 p
Physical Address,City,and Zip R' ff.
qp fL
county Q D Ni O&3( 21.REMARifB; pr,aliDn Pr,%-
hive!Idcmificatlon No.(PIN) `�'= 'ft Latitude and to
(ifwcll field,one lath longitude ci dt)"/Rdnutufi;eeonds or decimal degrees:
ong is autl6cioM)
3 °/0.
N—.-� 6 ZZ• 7 al / z2.Cc go j
ti.Is(are)the wells p W
()Permanent or o empora 7�zi -zz
rY Signal CoRIt)cd Wo11 Contractor
7.Is this a repair to an existing wen: Daeo
Ifth/s Lc a Er 13Yes or fS)vo signing this farm,I hereby cerl(jy that the rve//(aJ was
pair.m ad knoraE well n thettctlon fyJorarotlon and explain the natuir the rn o this r (u rv)ronstruated ht accordance
avlh 15A NCAC D1C.0l00 or lSd NCAC 01C.0200 Well COnslrttctl0n Slatdads and that a
repair trader#1I remarks section omen the backoflhtsjorm. 4r Py r ccond/ms teen provided to the%ell.wire►:
9,For Geoprobe/DPT or hosed-hoop Geothermal Wells having 23,Site d
constnrctio You may a erthe back of thispageWell
to
4 only I GW 1 is needed. Indicate TOTAL ng the same provide additional well site details or well
drilled: NUMBER of wells constructtoa details, you may
9•Total well depth below land surface: � ~ Y also attach additional pages if necessary
3UBMIT'rsr IagTR[1CrIANa
Far ma%Np/e wellS!/Staft depths U'dffreEa(example 3@200'aad 1©l009
(ft.) 24a. For n e i
10.Static water level below top of casing: Construction to the following.Submit this folyn within 30 days of completion of well
llwaterlavo//Sabovecas/nS.Else +' (ft.)
11.Borehole din Division of Water Resources,Information Processing Unit,
meter: (in.) 1617 Mail Service Center,Ralel
12.Well construction method. g�NC 27699.1617
ROTARY above,
-For Inteetlon ells; In addition'to sending the form to the address in 24a
(i.n.auger,rotary,cabin,direct push,eels) above,also submit one copy of this form`'within 30 days of completion of well
construction to the following: i FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Lo jection Control Program,
13a.Yield(gPID) 1636 Mail Service Center,Rate
Method of test: AIR ROTARY i$h,NC 27699.IW6
13b.Disinfection type: HTH Y&Forltur Wa-- t1.i Inte�en
the aadress(es) above, also submit o copy of this form within 30 days of
Amount: C --`•��• In addition to sending the form to
completion of well construction to the county health department of the county
Form GW.1 where constructed. f
North Carolina DepaxmentofEnvironmontal Quality-Div)sionofWaterResources t