GW1-2021-07427_Well Construction - GW1_20210921

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WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter WATER<ZONES =
WCII Contractor Noma '�^�- FROM TO DESCRIPTION
4448A °� ���'��� 44 H(P s' n
CL NC Wall Contractor Corti6cation Numb ci ��Q t�Ge✓5 ft. it.
� r�pt� IS:OUTER CASING forroultbcoaed;we0e OR<LINER%tires"AmbleL
Cummings 1Deveiopments Inc. ;nor ce� FROM To DIAMETER TH1craUEss I MATERIAL
Company Name �� *t fL `L a �' PVC
� HA NNE OR.TUBING("etitliermal:closedaSo s: '
2.Well
Construction Permit#: (A�,Q I -- CY)l�('> FROM TO I DIAMETER I TMCLNESS I MATERIAL
List all applicable Iwell eonstructton permits Air.Ulf,Catutly,State,Vartunce•etc.)
3.Well Use(check well use): ft. ft. In
Water SuPP4'Well: 19:SCREEN
*:
Agricultural FROM TO DIAMETER SLOT SIZE THICMSSS MATERIAL
�Municipal/Public f(, R, n.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. In.
IndustrialtCommercial DResidential Water Supply(shared)
k lion IS:GROUT, _ _ _ -
..�... x::.._.
FROM To MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 ft. PO it. Pan Cement Pour
Monitoring Recovery fL
Injection Well:'
Aquifer Roche rgo [313roundwater Remodiation
Aquifer Stora Storage t9;SAND/GRAVEI:;P•A6K;iia lleabte a 'Y•: u ¢.,r77
$ Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft.
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) 13Tracer 20tDRILLING.LOG:attach u$dltlonahsbeete iffnecea"s`a`
Geothermal(it eatin Coolie Return) nOther(explain under#21 Remarks) I FROM TO DESCRIPTION(color hardness,eolilrock e,grain sire,etc)`
ft. 11 rrt. Sol' )
4.Date Wells)Completed: Z( Well ID# it. WA it,
5a.Well/Location:
lJ�l1 1 Cl- ft. &
Facility/Owner Namc Facility ID#(if applicable) ft• f•
t o.1l-1 Ot A9 '�P( t r I'h trd I�A 115 541 �. fL
Physical Address,Qrty,and Zip ft. fL
9 Y U ZI REMARKS
County Parccl Tdontittcation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laillong is sufficient) t 22.Cerdficatio
W 9'3-V
6.Ware)the wells)f Permanent, or 13Temparary Signafuro of C;ogModVcl1 Contractor Data
8 rug this form,I herrhv cerljry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well' [3Yes or ffJNo Ili 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards mid that or
If this Is a repay f/i oat known well construction h tloramtlon and explain the nature afthe copy of this record has been provided to the uell owner.
repair under#21 rMizrks seGion or on the',back ofihisjann.
23.Site diagram or additional well details:
8.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
60 SUBMITTAL INSTRUCTIONS
drilled: fac /yy
9.Total well depth below land sure: (ft-) 24a. For AA Wells: Submit this form within 30 des of con letion of well
For multiple nulls list all depths ifd{B'ervnt(exmnple-3Q200'and 2©100� construction to the following: � P
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is Shove casing,nse + 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (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 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,
1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm): �+�� Method of test: Air Rotary 24c.For Water Sungly&Inle Ition Wells: In addition to sending the form to _
the address(es) above, also submit one copy of this form within 30 days of
13b.Dlsinfection�lype: HTH Amount: 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