GW1-2021-04190_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14,WATERZONEs
Well Contractor Name FROM 7.0 DESCRIPTION '
4448A ft. ft.
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING(for Auld4ased;wella)`OR<LiNERs if a livable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft ft. 1 6 in. PVC
16.INNER CASING OR TUBING(eothermal`closed4bo
2.Well Construction Permit#: wQ O - 0 Q-7 O FROM I To DIAMETER I TBmCKNEsS MATERIAL
Lint all applicable well canstruction permh(i.e.UIC,County,State.Variance,etr.)
3.Well Use(check well use): ft. 8. in.
Water Supply Well: 17.SCREEN-, 1 = -
A iCnitulal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
E3Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single) ft. k. In
Industrial/Commercial Residential Water Supply(shared)
;_IS:_GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
JE
n-Water Supply Well: 0 ft. 20 ft. Pon Cement Pour
Monitoring Recovery ft. ft.
ection Well:
uifer Rechar ft. ft•
9 g' �GroundwatcrRcmediationquifer Storage and Recovery @�Salini Barrier 19r'SAND/GRAVEL PACK ifa licable�I ty FROM TO MATERIAL EMPLACEMENTMETHOD
quifer Test E3Stormwater Drainagexperimental Technology Subsidence Controleothermal(Closed LOOP) [3Tuacer 20i DRILLINGL`OG attach additional sheets ifneeessaeothermal(Heating/CoolingReturn) Other•(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/rack n sire,etca
ft. �L ft. r
4.Date Well(s)Completed: Well ID# 2 ft. it.
5a.Well Location: R• n• ,,,.-^-�
JD g ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
118 hr e.Ze-1� '"C'r I ft. ft. AV
Physical Address,City,and Zip ,/ Q ft. ft. + ^C
�' Q63 7�1y 7�1 I 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lot/long is sufficient) 22.Certif o // //����,,^
3G' d, -6 N -79 00 3 •C W 3�(O�Os'idf'
6.Is(are)the well(s)oPermanent or Temporary ignatt cnificd Well Contractor Date
y signing this form,I herehv certify that the well(i)was(were)constructed hi accordance
7.Is this a repair to an existing well: 13Yes or MNo with ISA NCAC 01C.0100 or i5A NCAC 02C.0100 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/,�SIG SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (0' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For•multiple wells list all depths if different jerannp/e-3Q200'and 1QI00� construction to the following:
10.Static water level below top of casing:- 3 A (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 Injection 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, construction to the following:
ge tary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ` o Method of test: Air Rotary 24c.For Water Suonly&Info l tion Wells: In addition to sending the form to
C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: U ��Z 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