GW1-2022-10094_Well Construction - GW1_20221104

WELL CONSTRUCTIO RECORD GW-H —
r ti Well Contnctr:infor , For Internal Use Only: Pont FGfn
ration:
CHRISTOPHER WATCHER
Well Contactor Nano 4 WATRR7AIYFS
4448A FROM TO DESCRIFPION
NC Weu Conha$t°r Cmt(Rc°lion Numbm `
CUMMINGS DEVELOPMENTS , INC R H
Is.CUTER CASING for moltl-raged well$ OR LINER if.
C^�^P°^y Name M TU DIAMETER °
�t ` r H ft. J ft THICKNega MATERIAL
1•Well t:OOefryeti00 Permit N: 5 191 LV LZN z Z �_1I 65/8 In. .tee Lu[aIlgpp([cablr wr/lronrrnrrrioa penrd+•r(.r.U/C.Couny,S[arn, Irar/agrr,r/r.) 141NNRR CAOhVG OR TUBING G.STEEL
PaOM To eothermsl closed-laa
3,Well Use(check well use): R DIAMETER THICKNESS
h in MATERIAL
Water Supply Well: n. h.
a
Agricultural 17.tICREEN
Geothermal(Hg/Coo
eahn Supply(single)OMunicipal/Public FROM TO of 'MIR SLWI-Si E
ljng Supply) ®Residential Water Su I R' It..• THICKNESS MATERIAL
IDdustliaVCommercial
kri lion OResidential Water Supply(shared) ft. n.
in.
NonWater Supply Weil: 1s.cRDUT
PROM T, MATERIAL
Monitoring O R EMPLACEMENTMETN006pMOUNT
Action Well: Recovery 20 R• PORT.CEMENT POUR
Aquifer Recharge n• h
Aquifer Storage and Recovtay OGrOundwRter Romcdiatim R• h
Aquifer Test 09alinily Beerier 19.SANp/GR V"PACt(
FROM IsFxpelimental Technology OBtormwater Drainage, AL TO ft.OSubsideoce Control MpTERIpL LMPI.pCP.ME,VT MaTHUD
Geothermal(Closed Loop) R
OT11" FI
Geothermal Hest Coohn Return) 19•DRD.LINC LOG adsehadditimtaleb e etaifnecu$a )
01hm• ax lain under 1121 Remarks PRO M 'to
4.Date Well(s)Cam let _ O�RIPTION[o, N.M.
p ed: 3 O' fL e, min shy etr.l
Se.Well Location: Well
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F¢ility/Owmr Namo R. R
3L a(, �i Facility Joe(ifapPu dbJ) IL -
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Teo Cly anJ Zip r'tL�w� « IN. h
h
h
2 County 5'22 5-3 31.REa4ARRg LJ
Parecl Idcnnantion No.(PIN)Sb.L$ti o and longitude in degrees/minotes/seconds or decimal degrees:
(if-ell field,ld,ono lagloog u euf0cicnt)
3�DEl) 0 31
1^G
N 11 22.Certir,
� • b'oc µ,
6.We")the weli(i)OPeymanent Or oTemponry _
7.Is this a re ILf Wr°of Well COMmeb r !,
pair to an existlog well: D.rc
f/hu k a re/erlr. !1 ald ❑Yes Or ®No �•s 8 This fasr,/hrrrAv cxrl/fy[bl[he
'e kn., -1 conrevc0aa 1h sfo m. and rrP/aiu[hr nanny a Ih cn /dA NCAC OIC.O/00 or/SA NCA C 07C.0100/W rC rMrcNogconstructed
$ly dmdrra+�d nlra
rrpa/r agdrrd2/remarkr, rredgn°Ton the back af[hLJbrm. f PYl+hir rrr$rd/us hrnrPrvvidrd[o rk•uC."11rer.
S.For Geo rOWDPT 23.Site diagram or additional well details;
P or Closed-
consumStlon,onlyI GW P Geothermal Wells having the same You may use the back of this Page to
drilled; 1 Is needed. Indicate TOTAL NUMBER of wells conshuctiun details. YOU may also attachadditional tp pages if necessa details or well
9.Total well depth below land surface: 5 Z O SUBMITTAL INSTRUCTIONS For muhiPlr wrllr Its/o/l drp(Ar/fd.ff,e,+Icranrp/r-s—@2—o0'a)nd tat—om)
(fP) 24a.cous D Wells: Submit this farm within 30 days of completion of well
]0.Static water Tavel below top of Wang: / °onsteuctiDi to the following;!fwq[er/cue/u ahgw caring.qee•.�..
(R') Division Of Water Resources,Information Processin
1 L Borehole deametor. 1617 Mail Service Center,
��(in.) Raleigh,NC 27699.1617 nit,
t2.Well construction method: ROTARY 246.For inieetion Wall"
(i""aged rota above,also submit one In addition to sending the from to the address in 24a
ry,Sable,SUPPLY
Pugh,etc.) copy of this form within 30 days of completion of well
FOR WATER SUPPLY WE "Instruction to the one
following-
WELLS ONLY: Division of Water Resources,Un drgroundjection Control
134.Yield(gprn) � 1636 Mail Service entter,Raleigh nNC 27699.1636 Program.---� Method of test; AIR ROTARY
13b,Disinfection 24°•For Water NuoDly&Int H bPec HTH the address ��—We - )n addition to sending the form tO
�� Amount: SZ rt (es) above, also submit one w�_. completion of well construction to the count py of this form within 30 days of
Form GW_I where constructed, y health department of the county
North Carolina Department ofEnvironmo°tal Quality-Division of Wamr Romume,
I