GW1-2021-04186_Well Construction - GW1_20210401

1�3P rant Form
WELL CONSTRUCTION vRECORD(GW-1). For Internal UsdOilly:
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name A [t. i fr.
4448A 'St• 1 L ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multixased wells OR LINE&its licable
Cummings Developments, Inc. FROM TO I DIAMETER I THICKNESS I MATERIAL
+1 fL OT ft. 6 in. PVC
Company Name °`
``�\\ 16.INNER CASING OR TUBING:(geothermal closed=too "
2.Well Construction Permit#: lJ.J 2+�- D vs 2 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well constrttctimt per7rrits�.e.UIC,County,Stute,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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
Industrial/Commercial nResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Port Cement Pour
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK(if-applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20;DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain sin,etc.)
it' V6 ft.
4.Date Well(s)Completed: -Z -Z Well ID# g fr. ft
5a.Well Location:
�oQj_A VQC '4XJ ft. ft.
Facility/OW116r Name Facility ID#(if applicable) ft. ft. o 4
Z7278 .
3Q U Cav r S�� 'mod , Ce�Ir�r �In� ft. fL
Physical Address,City,and Zip ft. ft. APR X2021
21.REMARKS
r
County Parcel Identification No.(PIN) vrOn
Qcessin
5b.Latitude and longitudVin degrees/minutes/seconds or decimal degrees: 00000F
(if well field,one lat/long is sufficient) 22.Certification:
_ 36"' Q' U• 8SIN - 61• X ;R- uP9 W Z-ZS•Z �
6.Is(are)the well(s)oPermanent or Temporary Si uc of cd Well Contractor Date
rgnhrg this jotm,l herehv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or E[No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction tnforniation and explain the nature of the c'opypf this record has been provided to the well owner.
repair under#21 reniarks section or on the back of7his 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS''
9.Total well depth below land surface: 1 IN 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3 ac 00'and 2@100') construction to the following:
10.Static water level below top of casing: /y (ft.) Division of Water Resources,Information Processing Unit,
If hater 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
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) p
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
r Rotary 24e.For Water SuDDIv m Iuiection Wells: In addition to sending 13a.Yield(gpm) 2 Method of test: Ai Rt s the form to
the address(es)
above, also submit Zone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: �st92 completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016