GW1-2022-07639_Well Construction - GW1_20220817

_ « WELL C®NSTRUCTYON RRCOM GW 1 � .Piro#�Forrr
' I.Well Contractor Information: For Internal Use Only: 'I
Christopher Wachter
Well Connector Nome 14..WATERZONEB �
FROM TO D6aCplp77ON
4448A R. R• )11 2 ) S
NC Well Contractor Cottifleation Number R'
Cummings iDevelopment8 Inc. 15.OUTER CTO for nitilkrased,wepa
t FROM To DiAMBTBR T1nCiCVEBti MATERIAL
Company Namn +t R' ILa �• PVC
2.Well Construction Peradt#. -1 L{s 16.INNER', ING OR TUBING eottiermnl:closed3oo
blot all applicable well crons/ructlon permits tie.U1L;Cowl t�ROM ft.
DIAMETER `
r1:SYute,Farlunee.ete� TBter<Nsss � MATERIAL:
3.Well Use(check well use):
R. iL
Water SuAAw
Agricultural 17.SCREEN
0Municipaypubne ertoM To DIAMETER scarstzs 4 TRicrcnEse A
(leothemlal(Heat) o0n @. R, in. MATERIAL
�Clig Supply)Ap Y) �Reaidential Water Supply(single)
Ind ustriaycommercial DResidengal Water Supply(shared)
Irri tion PP Y( 18.ciROUT,.. .
Non-Water 3apply Well: FROM To ninrearAL v.: s,'°.
f EaIPLACPd1tENTsrersoD'•.AMo
Monitoring 0 R• 20 R. Pot Cemant Pour
action e : Ra every IL
Aquifer Recharge ®GroundwaterRomadiation R• R.
Aquifer Storage and Recovery Salinity Barrier ��M/O A`!EL PACK .q Apt610 _
Aquifer Test MA
�Stomtwater Drainage R. METROD
Experimental Technology Subsidence Control
Geothermal(Closed Loop) R' R'
�T`gCe1 zo:DRiLLW y Lao mace addlaoaw
Geothermal Heatin Conlin Return) Other(explain under#21 Remarks Oat To
D!B iPr[ON ruler hard° rdl/roelt eta
4.Date Wells)Completed:7' 'Z Z WeU D R.
!)/ R.
so.WeB Location: R,
• 4 R.
Fag tltty/OwwrNamo
Facility ID#(if appllcabk) R. ft.
IVA
Ph leat Addren City, . _
, ww i.�p R. R.
e'" 21 RE Ks � Unii
county tpLA Z - t3 a
Parcel Identification No.(PDJ)
Sb.Latitude and longitude In dellms/mlautp/aeconds or decimal degrees:
01 wail field,one hillong is sullident)
N�•
6-Is(are)the woll(s)OPermanont or Temporary S of Certified Well
Contra
Date
7.Is this a repair'to an etdsting well: Yes or ®No By signing this fmun,I heirgv ce"'I y'hut the weft)ryas(were)coaa7rt d d in accordanoe
(fthhr is u repair,fJUoul knoxrt we7Jconstuction hrlbrourtion and explain the nature of coPY ql rh�nrcord has been provided the xrU o2� ail Cmutnuctlon Standards mud Ihot a
npafrunder#21 mmarkssection or on thebackofthisforot.
8.For Geoprobe/pP1 or Closed-Leo Gen 23•Site diagram or additional well details:
9.Fortction,only i GW 1 Is needed.+Indic o nmlTOTA N MBBR f wells a 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 ifneeessary.
[/�) SUBMITT i,nvcrRrtr�rrn*S
9.Total weB depth below land surface: /V
For multiple xr118 list all depths U'I(example-30100'mid 1®/00) (R•) 24s. For All Wets: Submit this form within 30 days of completion of well
^ construction to the following:
10.Static water level below top of casing:_ e!
(fiuoler lever Is ahoy casing:ear"+^ (D) Division of Water Resources,Information Processing Unl%
11.Borehole diameter: 6 1617 Mail Service,"Center,Raleigh,NC 27699.1617
(re.)12.Well consttnctt0n method: Rotary 246.For Infection Wen■;
In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
(Le.eager.Many.cablt direct push,arc,) construction to the following:
FOR WATER SUPPLY W S ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 2769961636
138.Yield(guru) Method of test: Air Rotary
24C.For Water Saenly&rnieeden WatL■, In ndditioa to sending the foam to .
13b.Disinfection e: HTH �J�/ the addresses) above, also submit one wit
COPY of this form within 30 days of
Amount: —`QL completion of well construction to thO county health dorm wilt of the county
where constructed.
Form GW-1 Nardi Carolina DopaiLwnt ofEnvironmantal Qwiity-Division of Water Resowrca
Revised 2 22 2016