GW1-2022-05911_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD(QW4) For Internal Use Only:
1.Well Contractor Infornuttlon:
Chdstophdr Wachter 14.WATERZONES -
Wall Contractor P(ame FROM TO I DESCRIPTION .A
4448A rt. rr.
ft. it
NC Well Contractor Certification Number
I 15:OUTER�CASINGr for`:ieultl=rn9ed`,ivells=DR�LINER:ifie-'li¢alile�'_a� -.._` �"��..
Cummings Developments; Inc. FROM PTO DrA ETER THICIaVEss MATERIAL
Company Name +1 R• ( ft. 6 in. t iga 40 5ee I
MANNER ING ORTUBING:("rottierniahelosed=lira
2.Well Construction Permit#: FROM TO I DIAMETER ITHICKNESS MATERIAL
Llstall uppfirahloweNeonstructtorrpernrlts(i,c.UIC,County.State.Ya4unce,eta) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.- -
A ticultunt, TO DIAMETER SLOT SIZE THICKNESB MATERIALg DMunicipal/Public ft.Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft ft.InduslriaUCommercial13Residential Water Supply(shared)
[FROM
8.-GROUT,.. _ _
Tlri ation ROM TO MATERIAL ~ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PoaCement Pour
Monitoring 1 DRecovery It rt.
Injection Well:;oft ,
Aquifer Recharge R• ft.
q �g �Groundwator Remedietion
Aquifer Storage and Recovery Salinity Barrier -19Z sAND/GRAVEI;;PA6Ki ifia lligble r=
FROM TO MATERIAL IEMPLACEMENT METHOD
Aquifer Test i 13Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. It.
Geothermal(Closed Loop) i 13Tiacer 20iDRILL'ING10G;attacbiaddltloinalshei
Geothermal(Heating/Cooling Retulin) nOther(explain under#21 Remarks FROM TO DESCRI ON(color,hardness,soll/cacii a size.etc.)
ft. ! ft.
4.Date Weil(s)Completed:20'2iyell ID# 31 ft. ft.
S .Well Location:
t.ir1 I-(ekna n deb ft. ft.
Facility/Owner Nama Facility ID#(if applicable) ft. ft.
_70 �Sk l� rp % f..
Physical
l � Address,City,and Zi ��ll /_ ft. ft I f1,o, .l P ;r,;,1 U Z is
l ka I�t7. ef/a!� ZI:REMARKS:_ _
County IParcel ldenlification No.(PIN) ,
Sb.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la}/loag is 7fficient) � 22.Card
W
6.Is(are)the well(s)oPermanent; or Temporary uo of Certified Well Contractor Date
By signing this form,I herehv certify that the wells)1vas(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONO with 1SA NCAC 02C.0100 a•1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill oul known well eonsaitction lrllorniation and explain the nature ofthe copy gt'this record has been provided to the well owner
repair under#21 remarks section or on the%ack ofllrisform.
23.Site diagram or additional we➢1 details:
8.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed.j 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: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnalliple wells list all depths 1fd1ffFrenlj(erauple-3 rt 200 and 2©1005 y p
construction to the following:
10.Static water level below top of cuing:. (ft.) Division of Water Resources,Information Processing Unit,
Il water level is above casing ase•'+"
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: Rofary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) I construction to die following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)! Method of test:Air Rotary 24c.For Water Suoyh &IntecHon Wells: In addition to sending the form to .
13b.Dieinfectionitype: HTH Z the address(es) above, also submit one copy of this form within 30 days of
Amount: 7 completion of well construction'to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmontal Quality-Division of Water Resources Revised 2-22-2016