GW1-2022-07637_Well Construction - GW1_20220817

MCORD(GW-1
1.well contractor informal,.., For Internal Use Only
Christopher Wachter
wraluonnectarName 110
FROM
D ON
408A R. ft. 0 1 O^
1
NC Wall Ca fL
[On Number
Cummings, 16.OUTER CARING IBI oadwas O' W,.L'_VMM
CoI Nants Developments Inc. mom TO DI THI
6 PVC
2.Well Construction Permit g. 1811 16.IMER'C"ING OR TUB
RROM TO DIAMETER
3.Wen Use(cheek well use): I...... County,State.Varknic.'I
IN
;��� In.
iiRFI���:
Agricultural 17:Sc
Geothemid(Heating/Cooling Supply) E3municipal/Public TO D B
JeRaidetiflill water Supply(single) R. In.
Industrlaycommercial LOT61 TMMH MA L
t* DResidentini Water Supply(shared)
I&GROUT
044pply Well-. FROM
q
itoring 0 20 • Pan Cement POW M AMOI
uft Recharge
[3`03'O
Non
'qo Men action e : Recovery ft.
AundWaterRomadiation
Aquifer Storage and Recovery 19.g
139almily Bonier is
JAquifer Test E E3Stonuwatw Drainage ft. OD
Experimental Technology
'a 13SUbsidence Control
300themUll(Closed Loop) IL
e2fingfCooling Return) 13Tracer 1 20 D did'
nOther(explain under#21 Remarks) FROM TO IMON
4-Date Well(s)Completed: - Well
IR-a ft.
W# R.
52.Well Location: R.
R.
ft.
Facility W#(if-ppl—I.M.)
Lo 1,1
06 IL
P I I y 3 1 11 0—ft,i-,—.rw——Z 40)............. ..........
oo&. 0000009 21.
County Pawl Idaniffleation No.(PIN)
gb-Latitude and longitude In ftul/11"Utellseconds or decimal degrees:
WWII field,ono lai/long is suffidaut)
3�o 7 j. qqq N -71Q 0 27-1�L 12.Certtiff
6-Is(are)tie we"(s)iMpernument or 131remporary SOB ofeard Well Contractor ?,Z
Date
7.Is this a repair to an eldsting well: [3Yes or J@No signhtg 'far'"'1 he'TAY cerl#y'hal the"eft(s)was(were)004811 la accord4ace
Fthislearepsh-,flU out known I&VII contirucilon Worinallon and explain e fislage a CO'C-0MCACO2C.0200WOPIlCO)ulmdlonStandvda d1hata
f1hisprm, 11,Mb cOPY ofthis record has heen provIded to the%vH o1swer
repair under#21 reffis*SeWan or on the back a '(1hp an
9.For GeoprobI or Closed-Loop Geothermal Wdh having the same 23.Site diagram or additional well details:
YOU May me the back Of this Pisa to provide additional wall site details or well
construction.only I GW­I Is needed.i Indicate TOTAL NUMBER ofwalls construction details. You May also alld additional pages ifuccelsitry.
drilled:
9.Total Well depth below land surface: SUBMUMAL MaRMIONS
For 1111111010%vik lkt all depths 1fd&-prent. 10-3@200'wid 2@(00t) —0.) 24a. For ALSeLs: Submit this form within 30 days of completion of well
10-Static water level below top of easing; construction to the following:
(livater kvel is abovecogiftZ assIiIJ Division Of Water Resources,Information Processing unit,
1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.)
12.Well construction method. Rotary 24b.El1EJS12SfiM_VY&_. In addition to sending die form to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
(I.e.aulw,rotary.cable.directconattuation to die following.. cl
R WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Prolimm,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield{Rpm) Method of test.,Air Rotary_ 24c. 1 on Wells: In addition to sending the form to
13b.Illsinfiction type. HTH Amount: die a 86(es) above, submit one COPY Of this form within 30 days of
zo IL completion of well construction to the county health department of the county
----------- where constructed.
Folm GW_I
NOfdl Camllne Department of Environmental Quality-Division of Water Resourm Rovised2-22-2016