GW1-2021-04183_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 10 ft. ft. SCt
4448A i @ it. ISq ft. 3 6 a S9
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased'wens OR LINER if a licable _
Cummings Developments, Inc. FROM TO I DIAMETER THICKNESS MATE L
+1 fL ft. 6 5foLl
Company Name ( O -
I&INNER CASING OR TUBING( eothermal closed-loo
2.Well Construction Permit#: W Zo 2 lG1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft port Cement Pour
Monitoring . Recovery ft. ft.
Injection Well:
Aquifer Recharge E3 Groundwater Remcdiation 19.SAND/GRAVEL PACK(if applicable)'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stolmwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20;DRILLING LOG attach additional sheets If necessa*
FROM TO DESCRIPTION(color,hardness,soiVroek e, rain size,etc.)
Geothermal(Heating/Cooling Cooling Return) - Other(explain under#21 Remarks) 0 ft. IF ft. S /
of
4.Date Well(s)Completedq 1 Well ID# ft, o fr. 7 Gl
5a.Well Location: 1-1 f—aC+ ft. ft.
L)ov,nct SO" S
Facility/Owner Name Facility ID#(if applicable) ft. ft.
-
32,35 SUv,,A 1 ::� Lm 41 6wa&a 6 a7a76 ft. ft.
Physical Address,City,and Zip J ft. ft.
I JrC� $�6Io�0 S I g 21.REMARKS t: ^.�,ZS u t�'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifzw/ell field,one lat/long is sufficient) p ¢ 1 22.Certification:
6.Is(are)the well(s)oPermanent or OTemporary Si r erdfied Well Contractor Date
y signing this form,l herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
jthis is a repair,fill out known well carslruction information 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 this form.
23.Site diagram or additional well details:
8.For Geoprobe/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. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Q� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(erample-3@200'mud 2@100') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lntection 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:
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Rotary 24c.For Water Supply&Iniection 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 type: HTH Amount: X7V2 • completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourrccs Revised 2-22-2016
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