GW1-2021-07421_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christophor Wachter 14.WATE&ZOMS
Well Contractor Name • VJFROM TO DESCRIPTION
4448A S�Q e.4\9 R. ft.
o G ft. &NC.Wall Contractor CoreificarionNumber �O�,O�ReJgG�''O 15:OUTER:CASING(formulNaaied:weUs OR=LINER?da —bi ..
Cummings(Developments; Inc. ie�4�� p�, FROM To DIAMETER THICKNESS MATERIAL
Company Name '
+1 fLro L1It. s In. PVC
I&INNEWCASING OR TUBING;(eothermaliClortedaoo ._ ;_
2.Well Construction Permit#: - I I FROM TO I DIAMETER I THICKNESS I MATERIAL
Lill all applicable iwell construction permits(i.e.U1C.County.State,variance•etc.) ft. R. in.
3.Well Use(check well use): ft. it. in•
Water Supply Well: 17i SCREEN.- - ,- r _
AgriculturalMDn1Ci al/Pub1iC FROM. TO DIAMETER sLwTsizE�uTHICKNB88 MATERIALjy»
p ft. ft. in.
Geothermal(11eating/C00ling Supply) Residential Water Supply(single)
ft.
hldustrialtCommercial 13Residential Water Supply(shared) ft. in.
19.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTy
Non-Water Supply Well: 0 ft. . 20 ft. Port Cement Pour
Monitoring Recovery
Injection Well:
q ;g' ®Groundwater Romediation ft. fLA Aquifer Rcchar fa fL
Aquifer Storage and Recovery 139alinity Barrier _19:SAND/GRAVEL.PACK;
RROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage n• fL
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) JoTracer 20 DRIL'IING,L'OG:attach addiflorral iihe'ete`3itioec'essti`Ft ' s«
Geothermal(Unki Coolin Return) Mother(explain under#21 Remarks FROM TO DESCRIPTION(rotor,hardo soll/rock % n sbw.etc.)
ft. ft. Zi 4
4.Date Well(s)Completed: - — ) Well ID# !i>
ft. 0 fL f
55aa.Well Location:
ft.
Facility/Owner Name Facility 1D#(if applicable) B• ft•
Physical Address,City,end Zip ft. ft.
0( � �4 q d `� L � 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(ifwoll field,one letAong' sufficient) k
Is 22.Certification: Ole J N110
001a7L1 '.
w
6.h(are)the wen(s)OPer nument, or DTemporary Si the of Cc ' di Contractor Data
mug tfits jars,1 herehv ce,?(Jy that the wells)was(weir)constructed in acco,dance
7.Is this a repair to an existing well: 13Yes or INNo with 1SA NCAC 02C.0100 a•1SA NCAC 02C.0200 Well Construction Mandadr and that a
Phis is a repair,f11/out known well construction blibrmation and explain Ike nature ofthe copy,fthis record has been provided to the well owner. j
repair under#21 reinarks section or on the;back ofthisfonn. r
23.Site diagram or additional Well details: ;
9.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.i Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled-
SUBMITTAL14141
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24e. For All Wells: Submit this form within 30 days of completion of well z For multiple wrlk list all depths ijdi erentj'(exa iple-3@200'0'and 2@100') construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
!f roarer level is above castrE use'+' 1617 Mail Service`Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Intecdon Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of ihis 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 m Air
(gp ), Method of test: Rotary 24c.For Water &Inlection Wells: In addition to sending the'foray to
/, the address(es) above, also submit one copy of this form within 30 dayS 0
13b.Dlsinfectiontype: HTH Amount: 7r �L 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 Rovisad 2-22 2016