GW1-2022-06265_Well Construction - GW1_20220628

WELL C®NSTRUCTY®N WORD GW Il -Pr nt:Forpr
' For Lrternal Use Only: -
L Well Contractor Information.
Christopher Wachter
W011 Contractor Nain 14.:WATERZONE9
4"BA FROM ft. TO ft DESCRIpfyON
NC WcU Contactor Coni$Cation Number ft.
Cummings'Developments; Inc. is:OUTER CASING fonmWti:caeed.weW'OB�INER dti" a :_
Cotnpatty Nsew
FROM TO DIAMETER TRICIQIE88 MATERIAL
+1 R• � ft. �,
8 PVC
2,Well Construction Permit#; �_ p00 16.INNER"CASING OR:TUB➢NG('eiithermal:dosed;Ioo
List all oppllrahlc;well ronstretrtlon perm/Gs(J t UIC,County,Slafe.Variance.etr.) EOM f4 TO DBAIIfETER
TRICf4�]ESS MATERIAL
3.Weil Use(check well use); ft.
W1tI I, ft. & in.
pPly Well:
Agricultural 1%SCREEN.
-. ,:.•:_;:-:�s" _. ._...__ �_. __. ..
13MunicipaUPnblic FROM TO DIAMETER SLOTBfLE THIC[CVF66 J
Qeothemlal(lieating/Coolin Su 1 R. (n, MATERrnL
g pP y) IMResidential Witter Supply(single)
htdustriaUCommercial DResidential Water Supply(shared) ft ft. in.
Uri tion Is.GROUT..
Non FROM 'r'a MwrERIAI. EMFLAC@a�NT MT•:1'ROD&ANi/)I1NT
Monitoring 0 R• 20 ft.
lgl
Recovery Port Cement Pour ection e III, fL ft
Aquifer Recharge �GroundwatcrRemediation ft. ft.Aquifer Storage and Recovery Salinity Betrier 19.'SAND/GRAVEL PACK: a licahle
Aquifer Test FROM TO RIAL —
DStomrwaterDrainage ft, ft MATE EMPLACEMF.IWrMETHOD
ExP"imental Technology �SubsIdence Control
Geothermal(Closed Loop) 13Tracer ft.
Gen e)mal WeDR➢LI:ING LOG anaoh'addifibdel®heeto if oeeesco
th (Hearin Coolin Retuta) Other(explain under#21 Remarks PR M TO
DESCRIPTION min,6ardn aefVroei� _ atu.etc)
4.Date We11 s �_ ® ft '
Wall(s) '1— Z• Well ID# � fr. � f6
go.Well Location:
art•:n �n�„�5�, ft.
Fact7ity/Owner Name Facility 110(if appUcablo) g: O. J U N d S TUL
PhYSlcal Address,rtii'i+�lti Gip
Ceu 21.REMARI(S
� lat Patxcl identification No.(P1A1)
(if well field,on
and longitude in degrees lmintittes/seconds or decimal degrees:
(if no llon$ia sufficient)
3�°J— // N 710 31,1 M 22.Ce ilea:
W
6.Is(are)the wq(s) Permanoat or — ZZ
Temporary Signeturo o cil Contraotor Date
7.YB this a repair to as existing well: Yes or �1110 grain Iasa.I hereby ce; y trial the ivell(s)was(were)constructed in accordance
If Ibis is a repair:J74 otAknown'Pell construction hilorlrtallon and explabt the na ire of the copy 0 hNCA�d1 as beet provided is Are ae11 Dune ell Construction Standards and that a
regalrunder#2l reiiwrkssecllon Oran lh0baek0f1b18.rrnr.
or
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same YOU
Site diagramsth back of this page to well additional well site details or well
construction,only,,I OW I is needed;Indicate TOTAL NUMBER of wells Y°u may P g p
drilled: construction details. You may also attach additional pages ifnee
P g essary.
9.Total well depth below land surface: JA SUBIu11TTAL INSTRUCTIANS
POP nmlllple Wells l0t aft depths i/aq(/erenr(exwnple- (�a00'mrd3Q/00) (") 24a• For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of ceaing:_ ,�Q construction to the following:
ifwaterlevel is above casI use III" (ft•) Division of Witter Resources,Information Processing Unit,
11.Borehole diameter: 6 1617[Mail Service Center,Raleigh,NC 27699.1617
(In.) 24b.Fo In addition to sending the form to the address in 24a
12.Well construction method: Rotary r Inlecflon Wells:above,also submit One copy of this form within 30 days of completion of well
(i.e,auger,rotary,cable,direct push,eta) construction to the following:
FOR It SUPPLY WELLS O1dLY: Division of Water Resources,Underground l gecdon Control Program,
/2 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test•Air Rotary
24e.Po�Water Smonly&rninetlon Wollet In addition to sending the form to .
HTH 13b,Disinfection
e: the address(es) above, also submit one copy of this form within 30 daysof
Amount: /.Got completion of well construction I to�the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnantel Quality-Division of Water Resources
Revised 2-22 2016