GW1-2021-05973_Well Construction - GW1_20211025

i
_ .WELL CONSTRUCTIO14 RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chlistoph®r Wachter ! 14.WATERZONES
Well Contractor Name FROM TO I DEWAI N
4448A ft. fL
NC W01 Contractor Codification Number ft. ft.
15;OUTER'CASING 06imultioceaed;wells)
Cummings,Developments, Inc. FROM ATO DIAMETER THICIOWS MATERIAL
Company Name +1 ft• it. a in. PVC
16:1NNERCA3INGORTUBING:('eothermaP.elbsed=loo i"
2.Well Construction Permit#: W Z O 0 7-to FROM TO I DIAMETER I TMCMES9 I MATERIAL
List al/applicable itvell construction permits(i.e.UIC,County,State.Vartunce,eM.) ft. ft, in.
3.Well Use(check well use): ft. ft. In
[Geothermal
Supply Well: 17:SCREEN -
.�
th
rP9Rj0MTO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMunicipal/Public ft. in
JaResidential Water Supply(single)Neod
en
triaGeother UCommercial ooling Supply � idential Water Supply(shared)
Inigationc:GROUT"=:.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 ft, 20 ft,
� Port Cement Pour
in
oring Recovery ft. fL
Well:
er Recharge [3Groundwater Remcdiation it. ft.
er Storage and Recovery 139alinity Barrier 19``g�D/GRAVF'I%''P.ACKi 8"'Bcebla
FROM TO MATERIAL EMPLACEMENT METHOD
r Test [3Stomrwater Drainage ft. fL
imental Technology 13Subsidence Control
ermal(Closed Loop) E)Tmcer 20`DRILLING:LOG attach sddIdaaa4sheetisifincessa �ermal lieatin Conlin Redrrn)' Other(explain under#21 Remarks FROM TO DESCRIPTION icalar.hard- .ourrocri fte,simin.tae,.tc.)
q 1 0
4.Date Well(s)Completed: 1`( Z I Well ID# �y ft• 'g10 ft.
Sa.Well Location:
fL
Facility/Owner Name Facility ID#(if applicable) ft, fL ES
C1uAs V\A•eytA4� ir tx& w1 .1151a ft. ft.
Physical Address,City,and Zip ft. ft. �tOr+e
9.1 9 o a Sao 8 I 21 REMnR1CS _ ..-. .::..:
County W.
Parcel ldontification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one hoong is aufficicm) 22.CertiRcatlon:
3t;° « .Q1D 1 N 7 0 Q . GO Z ( W -13 V Zl
6.Is(are)the w1woPermanent, or, Temporary Si of ed Well Contractor Date
signing this foim,I hereby certify that the well(s)was(were)constructed Gr accordance
7.Is this a repair to an existing well: Yes or �Na with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Siardards and that a
if this is a repair,fill out known well construction friforuiation and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 renutrkssection or on the back oflhisform.
23.Site diagram or additional well details:
9.For GeoP robe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.j Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
Q o SUBMITTAL INSTRUC-TIONS
9.Total well depth below land surface: Q (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11;l all depths ffdifferrm!(exmnple-3@200'and 2©1001
^ construction to the following:
10.Static water level below top of casing _- d_0 (ft.) Division of Water Resources,Information Processing Unit,
if ivarer•level it above caring,use
••+•• - 1617 Mail Service Center,Raleigh,NC 27699.1617
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); t Method of test: Aar Rotary 24c.For Water Supply&InteoNon Wolfs: 1a addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectiontype: Amount: 6 2 completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016