GW1-2021-02014_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 TO DESCRIPTION
Well Contractor Name ft. ft. �. IS C� C e t I
4448A ft. ft.
NC Well Connector Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a Besb e
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 1 6 in. PVC
Company Name
Y•` \\ 16.INNER CASING OR TUBING( eothermal closed-too
2.Well Construction Permit#: W 2_0 C 17 V FROM TU DIAMETER THICKNESS MATERIAL
List all applicable well construrtion permits(r.e.UIC.County.State. Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft, ft. in.
lndustriaVCommercial 131tesidential Water Supply(shared) 19.GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply Well. 0 it• 20 ft' Port Cement Pour
Monitoring Recovery ft. ft.
Injection Well: —
Aquifer Recharge Groundwater Retnediation ft.
19.SAND/GRAVEL
GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stotmwater Drainage
Experimental Technology [ISubsidcnee Control f<• f<•
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attacb additional sheets if necena
FROM TO DESCRIPTION(color,hardners,solFroch e, rain sin,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) /; ft 1-7 ft 1J I'
4.Date Well(s)Completed: R Well ID# 2 -7 B. -00 ft. 4,JG
ft.
Sa.Well Location: It.
0-COn(-(A � �e_S ft. ft.
Facility/Owner Name ' Facility ID#(if applicable) ;27 ft. ft.
C4O�o ey RDy, L o I�,�I ,c�( Ll_l�jC ft. n niN021
Ph sical Address,City,and Zip ft. ft.
p S- 3 a uY 21.REMARKS DW gC[t0
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iavlong is sufficient) 22.Certifscati � -
-36vd6 �i �i N1a03. U' w
6.Is(are)the well(s)oPermanent or Temporary 'Signature of Certified Wcll Contractor Date
�y signing this form,1 herebv cerllfy that the wellft)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill oil known well construction information and explain the nature oftie copy gfthis record has been provided to the well owner.
repair under#21 remarks section or on the back oJAis 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: lor^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:"0 (rt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 ct 200'and 2 c@100') construction to the following:
ncy
10.Static water level below top of casing: hJ (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 Injection 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) G ''� :Method of test: Air Rotary 24c.For Water Supply&Iaiection Wells: in addition to sending the form to
-7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /y 2 completion of well construction to the county health department of the county
where constructed.
Form GW-i Nonh Carolina Department ofEnvironnicntal Quality-Division of Watcr Resources Revised 2-22-2016