GW1-2022-07909_Well Construction - GW1_20220823

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I-Well contractor information: For Internal use Only: I 07t rM
CHRISTOPHER WATCHER
Well moor
4448A irROM TO ft. DESCRIPTIONz
40
NC Well Contractor Certification Number ft. lG
.01JUR.CASING-1—
CUMMINGS DEVELOPMENTS, INC FROM
ROM O a"dienble
Company Name +1 ft. TO 61 DIAMETER THICKNESS MATERIAL
2.Well Construction permit#: L6Q S3 q I& NERX 14 fils In. .186
O.STEEL
Lill-1/applicable well construction P C).. .......ounty,Slate,Variance,etc) PR jsw UK WRING� 7 -
F ��j F7`�;;;;
WWI$(I TO DIAMETER THICKNESS
3-Well Use(Check well use): ft. In. MA AL
VI I '711;Z1, In In.
Agricultural
umm
DMunicipal/PtIblic DIAftirrER s
Geothermal(Heating/Cooling Supply) THICKNESS ML
bidusWayCommercial ®Residential Water Supply(single) in.
JIM ion E]ResidenR.
fial Water Supply(shared)
OUT
Non-Water -
Non t S
- FROM
TO MATE EMPLACEMENT M
Monitoring 0 ft. 20 NO &AMOUNT
JIDQOC* e Recove ft. fL PORT.CEMENT POUR
Aquifer Recharge DGrOundWatcr Romediation
R.
Aquifer Storage and Recovery
Aquifer Test OS81inityBanier WSANDIGRAI LPA jfij-licablPROM To i
Experimental Technology 13StOMIWater Droinag. fL & AL E P E M EM'N'T M 2
(100ther[1081(Closed Loop.) 0Subsidence Control ft. IL
Geothermal HeTracer 20; LINGTInG sttach4ddIth$Ijjd'h-
rk FROM a eataffnieW --------
-0011:29 Return) n'Other(uplain under#21 Remarks) TO DESCRI �� _a;­
sww Ck e� n
4.Date Well(s)Completed:
ft Well Location: WeIIJlD# 41 ft- % r_
Facility/Owner Name ft.
Facility ID#(ifi-pp-11-bl.) R. %
to"1 k Y\ trues
�itPhySiCal Address.City.and Zip ft. rri . —. 11. nft
ft. fL
c...,y 17�3 0.��Q 41.REMARKS.
3 3 0�')
5b.Latitude and longitude in d Parcel Identification No.(PIN)
(if
field,one latfiong is sufrci,,t)egrees/mblUtes/seconds or decimal degrees:
CertIr1c
6.Is(are)the weff(s)Werm2laellt or J3Temporary Z
um OfCcrtifled Well Contractor
Datc_�_'zz_
7'Is this a repair to an existing well: By signing�hlscf)7,
Ph&is a repair,j711 on,known well cons11,1101,13yeS or Jallo �I herch
an le 2C oloo 0v cerlyyL4u''heUIvosNAV)constructed lit accord cc
arnJolion and xPlail 14*11 ISA NA r ISA NCAC 02C.0200W an
,1/ConstructionS,1"Pair under#21 remaphs section Or Oil the back qfjjjsf,,n,. I the nature ofMc coPYOfth d has beenprovidedto the Isvilolviler. andar&and 111al a
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the s 23.Site diagram or additional well details:
construction,only I GW_l is needed. YOU may use the back Of this page to Provide additional well site details or well
drilled: Indicate TOTAL NUMBER of wells-----------— us Construction details. YOU may also attach additional pages if necessary.
9.Total well depth below land surface: �16 5 WAKLria—MS—T&U—CTWO&S
For multiple W AN its alldepilis ifdffi'erenj 1exoZp I @ 100 and;@0,) f*)
—1- — — 24'.&LAIII-W—eft Submit this fbrm within 30 days of completion of well
—I o—
10-Static water level below top of casing: 6 construction to the following.
Ywater level is clove casing,loe..+,, ng:
Division Of Water Resources;
,Information Processing unit,
I L Borehole diameter..6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i �
12. , ROTARY 24b.For JAe_2ft9my_elIs: In addition to sending the form to the address in 24a
Wen coustructiOu method: above,also submit One copy of this form within 30 days of completion of well
0-0.auger,rotary;cable,direct pus etc.) ---------------- construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,
Underground Injection Control Program,
1636 M
13a.Yield(gpm) Method of test. AIR ROTARY off Service Center,Raleigh,NC 276".1636
24c.For wo I
13b.Disinfection type- HTH the address4ftL&V&4kkWe1_10_n_F_& In addition to sending the form to
Amount: (es) above, also submit onelcdPY of this form within 30 days of
completion of well construction to the county health department
Form GW-1 where constructed. I rtment of the county
North Carolina Department of Environmental Quality.Division ofWator Resources