GW1-2021-02019_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 DESCRIP"ON
Well Contractor Name ft. ft.
•L
4448A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Cummings Developments, Inc. FROM TO I DIAMETER THICKNESS MATERIAL
+1 ft. Q ft. 1 6 in. PVC
Company Name vv
L 16.INNER CASING OR TUBING( eotherma►closed-too
L
2.Well Construction Permit#: H W 2-0 It - L) U FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernhits(i.e.U1C.County,Slate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFRON1 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public tt. rt. in.
Geothermal(Heating/Cooling Supply) lgResidential Water Supply(single) tt. ft. in.
Industrial/Commercial JoResidential Water Supply(shared) 18.GROUT
Irri ration FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o tt, pp tt. Port Cement Pour
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stoimwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION[color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) to ft. & tt.
4.Date Well(s)Completed: S'ZI Well ID# 17ft. ?(00 ft L J�
5a.Well Location:
� 1 ft. ft.
1 Jul 11 cA Tt a)
Facility/Owner Name Facility ID#(if applicable)
vLu�f„I n � , �I�M�E� �ld 07. tt.
Physical Address,City,and Zip ft. ft.
21.REMARKS
�CLi `79,q",00g145
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one]at/long its sufficient) 22.Certification
36 G L N -7 1 7b O s'R/Jf• a I yI(•//, t W
6.Is(are)the well(s)oPermanent or 07remporary Signatur Ccrti cil ontractor Date
By ng this forth,l herehv 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 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill oul known well construction information and explain the nature oflhe copy ol'this record has been provided to the well owner.
repair under#21 remarks section or on the back oj'this fornn.
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: SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: Roo (ft.) 24a. For A►1 Wells: Submit this form within 30 days of completion of well
For nultiple wells list all depths i/'different('example-3@[2000'and 2@100') construction to the following:
7 10.Static water level below top of casing: s (ft.) Division of Water Resources,information Processing Unit,
If hvater 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) I Method of test: Air Rotary 24c. For Water Supply&Injection 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: completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016