GW1-2021-02128_Well Construction - GW1_20210620

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- WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i.Well Contractor Information!
Christopher Wachter 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4448A % —
ft. ft.NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)PAL INER if a Ilcable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+t IL
ft s S in. O
Company Name 8U in
_ 16.INNER CASING OR TUBING(eothermal closed-loon)
2.Well Construction Permit#: LA 80 t)W E LN 2 I FROM TO DIAMETER I THICKNESS I MATERIAL
Lisl all applicable well consnurliot pnnettr(r,e.UIC,Cou ly.Stale•Variunre,elect n• ft. in.
3.Well Use(check well use): ft. ft. iD
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
g QMunicipal/Public g, fry. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft,
Industrial/Commercial13Residential Water Supply(shared) is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well. 0 n- 20 tt• port Cement Pour
Monitoring Recovery ft. ft.
Injection Well: —
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a Bcable
13SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage n• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets It necessary)
Geothermal(Heatin Coolin Return) Other(ex lain under#21 Remarks FROMI To DESCRIPTION(color turda sorUraek n else,eta)
fl ft. 6 o;S
4.Date Well(s)Completed: —Z�- Z, Well ID# ft. ft. — i�Ltd�l; _ _z
So.Well Location: ft. ft.
bo-A T1%Or-n+D" ft. & —
Facility/Owens Name Facility ID#(if applicable) (t- ft. —
53c? MC,t?wd-.a_
Physical Address,City,and Zip 1 it. ft.
A V -MLI.VI(,e_ G11 17 SI�tO 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field•one lattlong is sufficient)
22. i
N
6.Is(are)the well(s)oPermanent or Temporary Si ttue ofCenified Well Contractor Date
By signing this fo•nn,I herehv certify that the well(i)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or MNo wilh ISA NCAC 02C.0100 or/SA NC:AC 02C.0200 Well Construction Standards and that a
if this is a repair,fill 0111 known well construction information and explain the nature of the copy of•this record has been provided io the aril owner.
repair under#21 remarks section or on the back oj'this form.
23.Site diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
f�O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different!'erample-3Q200'and p2@1001 construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
(fevater level U above caring,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lniection 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:
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&Injection Wells: In addition to sending the form to
l.� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: (76Le 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 Wator Rcsourccs Revised 2-22-2016