GW1-2021-00729_Well Construction - GW1_20210401

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V�ELL'CONSMUCT�ION RECORD(GW I) For Internal Use Only:
1.Well Contractor Infor7nadon:
Christopher Wachter 14.,WATERZONES - 4 .
Well Contractor Name FROM TO DESCRIPTION
4448A 2
NC Well Contractor Ccrt(frcadon Number
is.OUTER`CASING(for multi-cssed.wells) 111INE ^if an llcable
Cummirlgs'Developmants, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Noms '
+1 ft. ft. g1 In. ..4 alb
Ca :16.INNER CASING OR TUBING eothermal closed-oo r
2.Well Construction Permit#: 39 l E" �Z»� FROM TO DIAMETER . THICKNESS MATERIAL
List all applicable wed ronsMactiwt pe,rttlta(I.e.UX County,State,Parlance,efc) n. a. in•
1.Well Use(check well use): ft. 8.
Water Supply Well: 17.SCREEN
Cpltural FROM TO DIAMETER SLOT SI7.E THICKNESS MATERIAL . -
13MunicipaUPublic n, n, In.
Gaathetmal(HeatinglCooling Supply) IgResidential Water Supply(single) R, ft. in.
htdusttisUCammercial Residential Water Supply(shared)
Irri tiori FROM TO MATERIAL EMPLACEMENT ErHOD&AMOUNT
Non-Water Supply Well: o fL 20 R Port cement Pour
Monitoring pRecovery
Injection Well:
A uifer Rccbar t R. ft.
9 g' �t.,mundwator Romoiliatian
Aquifer Storage and Recovery 19t SANDIGRAVEL!PACK ifa' ucabto
Saitriity Barrier FROM TO MATERIAL EMELACEMENT METHOD
Aquifer Test 3Stolrnwater Drainage
Experimental Technology °Subsidence Control It. ft
Geothermal(Closed Loop) OTiacer Zo.DRILLING:LOG fattai lt additlonai•sheets Itueees'sa tti '
Geothermal(Hearin COolin Return) Other(ex laintmder#21 Remarks FROM TO DESCRIPTION fcator ft. ft.. dardn solUmck Ine,Own she etc.)
4.Date Well( Completed:&13ERI Well ID#
So.WelfLocation: R• R• @� �"')'"
FFocilliity/OcanerName Facility IM(ifopplicable) D D•
s3tat Lk ft ft.
Ca t-.
PhysicaYAddress,City,and proWC c
'p►�iCJ,1v��littL ` �5�� f 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Ladtiide and longitude In degrees/minutalseconds or decimal degrees:
(if well field,one lettiong is an cecm) 1 22.Cerica
°` at �?31._ Nblb�S3 tIf w
6.Is(are)the will(s)OPermanent or ElTemporary ignatetro o Contractor Data
y signing this form,1 her00 mrllfy'that the nell(t)was(were)constructed to accordance
7.Is this'a repair to an'exisdngwell QYes or MNo wlth 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
Tfthis Isa rrpah;fdt out known well conitructlnn Wararation and explain the nature ofthe copy of this record htuc beets provided to the well owner.
repair under#21 remark section-or on the back ofthisforrn.
23.Site diagram or additional well details:
8.For Get►"robaMPT:or Closed-I oo Geothermal Wells havingthe some You may use the back of this page to provide additional well site details or well
construction onlyI OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:- SUBMITTAL INSTR CTIONS
s��t•�,,
9.Total well depth below land surface: �" tJ (ft•)For m 24a, For,Ali Wells: Submit this form within 30 days of completion of wellmultiple xrlk:tint all depths{(d!J/erent texansplr-3CSa 200''and 2(a)1007 construction to the following:
10.Statle water level below top of casing: 4[3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwalerleve!is above casing;use"+•' 1617 Mail Service`,Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a -
Rotary above,also submit one copy of this fornt Within 30 days of completion of well-
(i.e.Wellconsytcable.iirecthod: construction to the followin
{i.e:auger,rotazy,cable,tlireaK push.etc.) g'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm) a7lc Method of test: Air Rotary 24c.For Water Supply&Inlection,Wens: In addition to sending the form to
13b.Disinfection type: HTH
the address(es) above, also submits one copy of this form within 30 days of
Amount: doZ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Rcvlsed 2-22 20i6
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