GW1-2022-07596_Well Construction - GW1_20220817

;P�InfForm
-H—EL 'CONSTRUCTION RECQR D«���,� For Internal Use Only:
I.Well Contractor information:
CHRISTOPHER WATCHER 14 WAr>,RzolvU;
Wall Contractor No= FROM TO ID!$CRIPTION
4448A ff• ff.
ff. fL
NC Wall Contractor Certification Number i
is.OUTER CA81NII formotti eeied, ;OR•LiNER� :a" ble
CUMMINGS DEVELOPMENTS,INC FROM TO DIAMETER THi 8 MATERIAL
Company Name +t R. 6,f. 68/8 '
.T Itt. .168 0.8TEEL
i 16 INNER CAGING ORi1BING eotheetggl;daed-loo'2.Well Construction Permit#: ) 1 r I 1 �l 7 FROM TO DrAMETER TntcicNasB MAA' 1 List all applicable well cangirarlhm pennitg(Le.urc.Cotrnq;State,Parlance.eIC) R. ff. fn,
3.Well Use(check well use): ff, in.
Water 3uPP$'Well: i7.SCREEN;am
Agricultural FROM TO DAAMETE
�Mtuticipal/Public R BLOrsnz CiOtBSS MATERIAL
ft
[Aq
ermal(Heating/Cooling Supply) idential Water Supply(single)
trlal/Commercial R•
®Residential Water Supply(shared)
ion _ r,
FROM TO MATE 'AL Sa1PLACEMENTKMOD AMOUNT
ater Supply Well: o ff• zo R•
oring Recove PORT.CEMENT POUR
injection ff' R•
er Recharge E3Groundwater Romodiation ft. R
er Storage and Recovery [33alinity Barrier L PACK EMPLACEMENTMBTHOD
r'Test �StornmwaterDreinage te. iwimental Technology Subsidence ControlR.etmal(Closed LOOP) Tracer 20 DOG attachaddtermal ea' oling Return [;Other lain under#21 Remarks) FROM To DUCE
i oN eater traMo eaturoek v 4 eta►
v /
4.Date WcH(s)Completed: r 1—2 Z Well ED# ff. lid % Am
Sa Well Location: R ff. P'
_2�wrnt?S C11r(�y�S. ff &
Facility/Owner Name Facility JD#(ifopplicablc) R• R. y ,,f
p t r,
9022
Physical Address,City,and Zip ft. % vnr c.
� tmii
111�y1[�iR P �rd'1'1 031700121.REn�iARics. . ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeMullooWseconds or decimal degrees:
(ifwoll field,on*lot/long is sumclom) 22.Certlticq
UO )y .7 �-1 N�� `� �'? . 13 .2 W
-2z
6.Is(are)the well(s)OPermanent or 03Tempornry o Cortlfied Wall Contractor Data
By signing I t faun,i hemby cerlIfy thin dw well(:)teas(were)eonsintcled to accordance
7.Is this a repair to an existing well: ®Yes or JMNo With 15A NCAC 02C.0100 or ISA NCAC 02C.0200 iYdl ConslrucNon SYandmds and that a
fthia R a MXht JIB onl kaotwr well conanuellon iebrnrallon and explain the nalnr n ofthe ropy althig rrcard has been provided to the Wmdl mwrer
repair under#21 remadrs section or on the backofthlsjann,
23.Site diagram or additional well details:
L For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page fo provide additional well site details or well
construction,only 1 GW 1 is needed, Indicate TOTAL NUMBER of walls construction details. You tray also attach additional pages if necessary.
drilled:
SUBMITTAL INR'I'RUCTIONS
9.Total well depth below lend surface: J (ft) a43, For AI!Wells: Submit this�fwm within 30 days of completion of well
For muBiple W7118&I oil dapNts i(Off'rent(example-3@200'and 2©100) Ys P
construction to the following:
10.Static water level below top of casing: �®
/avcl br above casing,me (ft) Division of Water Resources,information Processing Unit,
Ifwater 1617 Map Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ROTARY above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta) construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground bdection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gem) ! Method of test:AIR ROTARY 24c,For Water SuoDiv&Iniection We la: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: HTM Amount: 10 Z completion of well construction to thb county health department of the county
where constructed.
Farm OW-1 Noah Carolina Department ofEnvironmental Quality-Division of Water Rosoumes