GW1-2022-07607_Well Construction - GW1_20220817

WELL C [STR 'CTI N RECORD(GW.1) For Internal Use only: l7l,�—' f
I-Well contractor information:
CHRISTOPHER WATCHER
well Contractor ......
448A FROM TO ft. DESCRIPTION
Well Conna-tor C011ifi-ation Number ft.
CUMMINGS DEVELOPMENTS, INC IS.OUTEXCASING.for.affidid eyed,vills 'RVINER is-u
Company Name FROM TO DIAMETER THIC It MATERIAL
2.Well Conaftedon permit#: 'o +1 ft. ft. 6518 Ift. .198 G.STEEL
List affqppjjrabjc,,jj -. �Ld�!FLW WINNE&CAASiN OR TUBING- "
eunstrurdon PIF171110 C1.e. — PROM DIAMETER
3,Well Use(check well use): U11C County�3-1111 js�"Y-11111 1111-3� ft. ft. In. THICKNESS MATERIAL~
Water SuPPh'Weil: ft. ft.
Agricultural 17.,SCREEN;
Geothermal(Heating/Cooling Supply) C)MuniciPalftblic FROM
TO ft. DIAMK`rKR SLOT SIZE THIC
oResidenfl,l Water Supply(aing ft. In. "IN MATERIAL
Indtistfrial/Cominercial 01tesidential Water Supply le) ft. • i in.
Irriation IY(shared) , I
-.3111.GROUT
Non-Water Supply Well: FROM TO MATERIAL E-M�
Monitoring 0 fL P CEMENT D& OUNT
eegion 20 PORT. POUR
R. ft.
Aquifer Recharge
oGrOundWater Romediation it.
Aquifer Storage and Recovery
Aquifer Test 13Salinity Barrier 1-9i'SAND/GRAVE�-PA
FROM TO MATERIAL
Experimental Technology [3Stormwater Drainage ft. ft. EMPLACEMENT M Rol)
0SUbsidence Control
Geothermal(Closed Loop) ft. It.
13Tracer I
Geothermal He8 COolingReturn) 20.D 1OGjattjCbjddI1i&ajah I( 1;t1l FROM Mecess
oath—er, D111in tinder#21 Remarks) DESCRIPTION cola
4.Date Well(s)Completed: ft. I bardy 110111rack etc.)
sa.Wen Location: Well IN IL .7-
6—
Facility/Owner Name ft. nn
0 Facility III#(ifs licabl c) R. ft.
Physical Address.City,an Zip I
%
ft
tat
21.BE
County le S-7 &t ft. &
MA
.............
PfIrccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds utts/Seconds or decimal degrees:
(ifwofl field,ono jatA_g is sufficient)
36 0 1 22.Certirica-
LLL�N 212L.4—YO-1 ' w
6-Is(are)the wafl(S)OPertnanfent Or OTemporary Si uro of crti
ZZ
7,12 this a repair to an existing Well: Sign If Cot tm-wr
-erl#- f/wt the wells)"s(Were)constructed In ac rdrace
her"Ay(' y/JIhls Le a repair Jill f
Date
I k.. b. Yea or Jallo $1 C 02C.Oloo or ISA NCAC 02C.0200 To
PFRair under#21 reorois,se,11011 , 100"Mallon and explain the,naltre!rh
or 01,the back ofilisjorin. 0 Ofthis record fiav been provided to th e V,,011 a IvnerW.c'Consft'Clian&andards and//,,I
8.For GeoprObe/DPT or Cl sed-Loop Geothermal Wells having 23.Site diagram or additional well t details:
construction,Only I GW-1 is Oneeded. Indicate TOTAL NUMBF ng the same You may use the back Of this page to Provide additional well site details or well
drilled:--------------- 'R of wells Construction details. YOU May also attach additional pages if necessary,
9-Total well depth below land surface:
For multiple
wells list aft deptin#1diff,,,j 1e1,11u,17-130200 ► 24a.E2L"y-eiis: Submit this form within 30 days of completion of well
10-Static water level below top of easing: construction to the following.
ff-rer law/is above casing,Five Division Of Water Resources,Information Processing unit
11.Borehole diameter:.6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Wen construction method:- k;j&e, ,24b.ROTARY I In addition to sending the form to the address in 24a
(i.e.auger,r0ta1X cable,direct push,etc.) 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 Injection Control Program,
13a.Yield(gpm)—Z—� Method of test. AIR ROTARY 1636 Mail Service Cenier,Raleigh,NC 276"-1636
24c.
13b.Disinfection type: HTH the 41L-W�alersu�*-ftk-1-1102A-Jeh: In addition to sending the form to
Amount: address(es) above, also submit one'coPy of this form within 30 days of
completion Of well construction to thel county health
where constructed. department of the county
FormGW-I
North Carolina Department of Environmental Quality-Division of Water Resourcos