GW1-2021-07353_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW4) For Internal Use Only:
I.Well Contractor Informittlont
Christopht;rWachter 14.:WATER=ZONES
e
Wall Contractor Name FROM TO DESCRI oN
4448A .� �'l,� ftn'
gNC Well Cantractbr Certification Numbci• '
C��Q ee�5�r IS:OUTER CARING for mult4eased:we0e iOR LiNER�d"-" cable "-
Cummings IDeveiopments Inc. pCOG n FROM To DIAMETER THicKNESs MATERIAL
Company Name ,t
LP I It S hL PVC
16:1NNER CASING OR TUBING "Hiiiodilbaii
2.Well Construction Permit#: )(0:S 0 FROM I To I DIAMETER I THICKNESS 1 MATERIAL
List all appfirahle pvell eonstruriion permits(Le.U1C,County,State,Variance,etc) R• ft. in
I ,
3.Well Use(check wen use): ft. ft ID
Water Supply Well: 17.`SCREEN•'
Agricultural FROM I TO I DIAMETER SLOTSiZE THICKNESS MATERiAL
13M ^\�r
unicipal/Public ft, ft. in.
Geothermal(lienting/Cooling Supply) oResidential Water Supply(single)
Industrial(Commercial 13Residential Water Supply(shared) ft. ft. in.
ilrl tine FROM TO ^� MATERIAL EMPLACEMENT METHOD&AMOUNT~,
Non-Water Supply Well: 0 ft- 20 port Cement Pour
Monitoring . Recovery
Injection Well:!
ft ft
Aquifer Rccha go [3Groundwator Romediation ft.
Aquifer Storage and Recovery _19.:SAND/GRAVEL PACK (f:a RcabioiY
g erYSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. &
Experimental Technology 13Subsidence Control R. ft.
Geothermal(Closed Loop) DTracer 20:DRILLING LOG:attaeb'additionel'ihce`te`:It:aeeessi(' '"`<w
Geothermal Heatin Coolin Retuin) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardnem somrocr e, yn sin.eta
J D ft. ft. oil
.
4.Date wen(s)Completed: 2 l' Z Well ID# ft.i
5a.Well Location:
�eXf LA ZY CA us 0n ft. ft
Facility/O atitc Facility ID#(if applicable) ft• ft•
La Kp F A- �I,)do►e- L D+ I'D ft. rt
Physical[ `.\Address,,city,and Zip v fL ft.
S lA o ` 4 0I g& ()&Y
County Parcal Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: A Air
(ifwell fiold,one laHlong is sufficient) I 2 e cation:
30 K gg of N :1?0 09, 1 SS( W $-Z`I•ZI
6.Is(are)the well(s)OPermanent; or 13Temporary Srgnsturo of Certified Well Contractor Date
By signing this form,1 herehv certify that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: E3Yes or JMNo wllh 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
(fthis Is a repair,flit out known well comititction lrtrantatlon and explain the nature ofihe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the;back oflhis form.
23.Site diagram or additional well details:
8.For GeoproWDPT 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,i Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTION9
9.Total well depth below land surface: 0 (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple%rlls list all depths if zi ereni�(example.ale!200•nd 2 1001 construction to the followin :
g
Static water level below top of casing: —7 r�
1f (ft.) Division of Water Resources,information Processing Unit,
tvater level is above casing nse^+ 1617 Mali Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 i (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 i this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) ! construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
' e 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)! Method of test: Air Rotary 24c.For Water Suenly&Inlel Hen 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: a I- completion of well construction"to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016