GW1-2022-07604_Well Construction - GW1_20220817

WEIJ,CONSTRUCTION REC---
+ For Internal Use ffbem
Only:
I-Well contractor Information:
CHRISTOPHER WATCHER
Well Contractor
to ER ZONES,
FROM TO DESCRIPTIONf
448A
NC Well '--t--tllr Cartificallint—Number ft• R.
or nifiltize'"'awells V ;LINER,' s—licisitle
AS.OUTEWCASING f
CUMMINGS DEVELOPMENTS, INC FROM TO D
Comp Name +1 ft. DIAMETER THICKNESSMATERIAL
Z.Well Construction Permit#- 5bjjp 66/8 .168 G,STEEL
16LIN E VASING'ORTUBIN
List all aPplirble well ons,..&,;elmllff— FROM TO WAME eO -drda"e-d.100S
67�Ulcz=ly' MATERIAL
3.Well Use(check well use): R. in. —TE
Water Supply
11 Well:ll 111:
Agricultural 17.SCREEN,
DMullicipal/Publi. FROM TO DIARISTE
R SLOTSIzE
ft. MATERIAL
Geothermal(Heat'ng/Coo"ng Supply) Residential Water Supply($in
Industrial/COMMercial
R.
Irri lionJoResidential Water Supply(shared)
Is'GROUT,
Non-Water Supply well: FROM TO
RIAL EMPLACEMENT M-
Monitoring Recovery
0 it. 20 PORT.CEMENT POUR LTROD&AMOUNT
Injection a R.
Aquifer Recharge DGroundwater Rarnediation ft. &
Aquifer Storage and Recovery E3S-linity B.rir 19.i - I
Aquifer Test 13StOmlwater Drainage IRR TO 77--
� EMPLACEMENT METHOD
Experimental Technology Subsidence Control &
Geothermal(Closed Loop.) FL
Mracer
Geothermal Heatin Conlin Return) 1Other(a X DRILLINGLOG attach-iiddItI6�aj:jfi
FROM
plain tinder#21 Remarks) fL DESC Jpjrlo
4.Date Well(s)Completed: Z7- Wel,M# 0
Sa.Well Location: --------- ft.
I Y/ow "N ft.
Fit—ALY/Ow r ............ 06.
--- ;7acilifty i"111111(ifaPPI 0) R."W tM Z4`Q,
4o - I
1111........................................ t�04 A
;h—)"deal Address,City,and Zip ft.
-19fr
1� 3 X(Q 21. MARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshWautes/seconds or decimal degrees:
(if wall field,0110 latnong is sufficient)
22.Cart
w
6.Ware)the well(s)OPermanent Or 13Temporary � Signal Certified Well Contractor 7--zP—z,-z
7'is this 2 repair to an existing wen: fly signing thrfann I he-Av vertify hot he Date —
9"hisivarePoll'-fill our knolva well or MON W/h ISA Nr-4C 02�'. consir"cled in a"".d...
n W01107'allan and"It"P0111111 ffir nature 0
repair under#21 remarks section Or 01,the back of jbisjopm. rib" coPY Of this record has 0100-'SANC.4CO2C.020"'I"C"Ill""Itlllad., andibala
ble"provided to till,iijallouner.
8,For GeOPrObe/DPr or Closed-Loa p Geothermal Wells having the same 23.Site diagram or additional well detalls:
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells You may use the back Of this Page to provide additional well site details or well
drilled.- construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 120 08M=aj_NSj&UcZ ONS
For multiple wells list all depills ifdWerem,1 0"T d2@100,) 242.Ev I Ws:Ag Submit this form within 30 days of completion of well
10-Static water level below top of easing: construction to the following.
If water level Is above casing.ine -+,,
(ft.) Division of Witter Resources,Information Processing Unit
11-Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.
ROTARY : In addition to sending the farm to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
G.e.auger,rotary,cable,direct push,a`ta7)----- construction to ale following:
FOR13b.
P WELLS Division of Water Resources,Underground Injection Control Program,
139.Yield(gpm) 1e5 Method of test. AIR ROTARY 1636 Mail Service cenIer,Rilleigh,NC 276"-1636 gra
I I �j 24c.11111*o—W—ater
3b.Disinfection Au"&411112-140-211AALS: In addition to sending the forip,to
3b.Disinfection type: HTH the address(es) above, also submit ,
Amount:---1210 t Completion of well construction to one,copy Of this form within 30 days of
Form GW.1 where constructed. the county health department of the county
North Carolina Department of Environmental Quality-Division of Water Resources 0--