GW1-2021-02011_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
Well Contractor Name FROM ro DESCRIPTION
�$A ft. ft. T)- -) 1:z 13
NC Well Contactor Certification Number
19.OUTER CASING(for multi-cased wells OR LiNER if a livable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft. L/ 1- 1 a in. PVC
16.INNER CASING OR TUBING( eothermal closed-loon)
2.Well Construction Permit#: W T O - 0,P11 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.U1C,C'ounly.State.Variance.etr.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
g QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MDResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. port Cement Pour
Monitoring rlRecovery
Injection Well: _
:)Aquifer Recharge ft. ft.
q g' �Groundwatur Remcdiation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK if a licablel
A
q g ry 13Salinity Barrier FROM TU MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stolmwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Ttacer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO I DESCRIPTION(color,hardness,soiuroelc type rain size,etc.)
ft. l)C ft. J'\
rT
4.Date Well(s)Completed: '�I Well ID# Lj ft. ft. •�iJL
5a.Well Location:
►A b 1.0 01.A .yl' ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
210 ('loos- Lvx Mcbany a 150 a ft. ft.
Physical Address,City,and Zip ft. ft.
olra,,,�Ag 218 313as9 A 21.REMARKS
County 1J Parcel identification No.(PIN) r. Processing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR Section
(if well field,one lat/long is sufficient) 22.Certification
3&`0� •aa7 N ?a° c • �l4a
6.Is(are)the well(s)oPermanent or 13Temporary S' of Certified Well Contractor ate
By signing this form,I herehv certify that the well(.0 was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or @No with 1 SA NCAC 02C.0100 or I SA NCAC 0?C.0200 Well Construction Standards and that a
Iflhis is a repair•fill out known well construction infurmalion and explain the nature of the copy of this record has been provided to the xell owner.
repair under#21 remarks section or on the back oJAis forin.
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:
/ , o SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welis list ali depths ifdi[ferent(erantple-3 rt 200'and-7@ 1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+^ 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
in
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 Supply&Infection Wells: In addition to sending the form to
011
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 41 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 Watcr Resources Revised 2-22-2016