GW1-2021-05906_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infornuidon:
Christopher Wachter 14.WATER-ZONES
Wall Contractor Name FROM TO DESCRIPTION
4448A ft. fL
NC Well Coahactbr Certification Numb": ft. ft T '2 "Z�A
15.OUTER".CASING for mWH=eeaed`weOt:OR<LiNER+da enure ^r-"'.
Cummings jDevelopments Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name +1 1L % 6 Im PVC
16:1NNER •ASING OR TUBING C euttiatvial clusedabo °- -
2.Well Construction Permit#: _. 17 Z)3 FROM TO DIAMETER THICOMS I MATERIAL
List all applicable well construction permits r e.U1C,County,State,vartunre,etc) ft. n, in.
3.Well Use(check well use):
jNon-Water
ater Supply Well: 17.`SCREEN F
Agricultural FROM TO DIAMETER SLOT Bl2E THICKNESS MATERIAL n,
�MunicipaUPublic tt. n. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ndustrial/Commercial D•
Residential Water Supply(shared)Irrigation IS.GROUT_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT"
Supply Well: 0 R• 20 % Pon Cement Pour
Monitoring Recovery iL it.
ection Well:
AquiferRccharge [3GroundwaterRemodiation R. &
Aquifer Storage and Recovery ti19.:SAND/GRAVEL;PACIC•.if a livable_ is � _ ; ° f
g tY Salinity Barrier FROM TO MATERIAL EMPLACEMENT'METHOD
quifer Test 13Stomiwater Drainage R• fL
xperimental Technology Subsidence Control
eothermal(Closed Loop) Tracer 20:DRILLINGaLOG attach iddtHonal she`ete;iGn`ee'eessA't _ _:,
eothermal Heatin Coolin Retuin) nOther(explain under#21 Remarks) FROM To DESCRIPTION color hardness.90111MWOR,RrAtB she.00 ^
R. ZO fL or 1
4.Date Well(s)Completed: 1 Q '4 Z I well ID# 2Q i7• fL
Sa.Well Location:
l• �.a�-Wl,-� ft. ft.
Facility/0�Name Facility 1D#(if applicable) ff• R• 2I
1a1 IL av\ I ; l ti 1 n %tY'ataWIP a7379 fL ft.
Physical Address,Cil, d Zip ft. ft. at'ron PIOce
013
_l t�l_ I�:� ` "2L REMARKS: <s_. _
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laNlong is sufficient) 22.Cerfitica
fir°Zlo- G.S 7 1 N -]10 Zl -q W l w 0-4-ZI
6.Is(are)the well(s)OPermanent, or Temporary egnattvo o fi c1i Contractor • veto
signing this form,1 hereby cerily that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If lhia is n repair,ill!oar known well eonshf,ction htfa n,alton and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of Ibis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Qosed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed.i Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wills 1Lst all depths!jd{B'erent;'(exanple-3Q200'and 2Q1oB� � p
,,\\ construction to the following:
if% Static water level below top of cAs9ng: �V (ft.) Division of Water Resources,Information Processing Unit,lfwater level is shove easln$else'•+° 1617 Mail Service Center,Raleigh,NC 27694.1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7CP Method of test: Air Rotary 24e.For Water Supply&Inleeton Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection;lype: HTH Amount: !e,Z completion of well construction to�the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Enviromnontal Quality-Division of Watcr Resources Revised 2-22-2016