GW1-2021-01985_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
FROM 'f0 DESCRIPTION
Well Contractor Name g, ft. Z L 3
4448A ft. I cd L
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells�LINERif a licableCummings Developments, Inc. FROM TO DIAMETER S MATERIAL
+1 ft- 2 ft. 6 in. PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400 )
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,variance,et(.) fit. fit. in.
3.Well Use(check well use): ft. fit. in.
Water Supply Well: 17.SCREEN
FHOhI '1'O DtM1E'I'EH SLOT SIZE THICKNESS I MATERIAL
Agricultural [3Municipal/Public fit. ft. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. ft• in.
htdustriaVCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p fit. PO fit. Port Cement Pour
Monitoring Recovery ft. ft.
Injection Well: —
ft. ft.
Aquifer Recharge Groundwater Remediation —
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT:METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control tt. fit.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM .1'0 DESCRIPTION(color,hardness,soil/rock e, rain sire,etc)
Geothermal(Heating/CoolingReturn) Other(explain under 021 Remarks) 0 ft ;
4.Date Well(s)Completed: —Z t Well ID# 9 L,7 rt. V fit. i
5a.Well Location: fit. (t.
Ntir \ont•. ���! 5 fit. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6416 14a0" 640M d lam(. 54tr Cli to ft. ft
Physical Address,City,and Zip ft. ft.
C'6kl a rv% y 0 0' 21.REMARKS 31
nq Out
County Y% Parcel identification No.(PiN) _ DWR S8d011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 1 22.Certification:
36ogi. gn' N 79° z8.941 W
6.Is(are)the well(s)oPermanent or 13Temporary SignatHnEof Cerlifcd Wcll Contractor Date
• ng!his J rm,I hereb'v certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: Yes or E)No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
//this is a repair,fill out known well construction information and erplain the nature of the 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓C�+� ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel/s list all depths ifdii ferent(example-3@200'andd2(e-_yi00') construction to the following:
10.Static water level below top of casing: 'U (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Rotary 24c.For Water Suvyly&Iniection 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: U completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016