GW1-2022-06272_Well Construction - GW1_20220628

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WELL C®NSTRUCTION RECORD(GW-1) For Ltternal Use Only: i_ !Print?Forrn ;
' :.Well Contractor Information!
Christopher Wachter
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A fc. rr. (A 78
ft. Ll • i 0q
NC Well Contractor Certification Numbor
ILOU..TER.CASING:(formWH=eauediwells_OWLiNER-'ifia"']i-atilcl::''-
Cummings Developments; Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Nome +1 ft, to_11 ft. g is PVC
16 INNERCASING OR-TUBING f eothei melfdlosed=loo
2.Well Constrticdon Permit#:�2,_000 7 mom To DIAMETER I TBiCi IMS J MATERIAL
List all apphrable well construction permits(Le.UIL�Cotmty,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
i
Water Supply Well: 17.SCREEN` _ - -
Ag1'lcultural f MImICi al/PUb11C FROM TO DIAMETER SLOTSIZE THICKNES6 MATERIAL
P ft. ft. In.
Geothermal(Heating/Cooling Supply) IMItesidential Water Supply(single) ft. ft. to
lndustriaUCommerciai 13Residential Water Supply(shared)
In- i FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Sapply Well: 0 ft. PO ft. Part Cement Pour
Monitoring f Recovery & ft.
Injection Well:l
ft. fLAquifer Rcch GroundwaterRemediationaig'
19.SAND/GRAVEL,t?ACK{if a liooble _ .. `
Aquifer Storage and Recovery �Selinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test MStormwater Drainage Et. ft.
Experimental Technology E3Subsidence Control R. ft.
Geothermal(dosed Loop) E311acer 20:DRILI3iNG;LUG;attactioddiHonelsheetetiEriecessa "ice °::_:;:,>"s:;,. ;=
Geothermal(Iiieatin Coolin Retuirr) Other(explain under#21 Remarks FROM To DESCRIPTION(color,h ss, elcardne soluro a rain size.etc)
t
a ft. qc 1
4.Date Well(s)Completed: 2 Z Well ID# !j/�'ft• $1 It-
- r)
So.
io Well Location: tl. U ft.
I
brlrla . a0 V'A � ft. ft.
Facility/Owner Namc Facility ID#(if applicable) H• ft J U N rr
711 A U41l2C+• t dct-r -fir Ve, a7a31 rL R.
:.. Sir , ;• [Jr1si
Physical Addres ity,and Zip ft. ft. »i4 �
A4- �8S9IcYH5$� Z1REIViARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one lai/long is sufficient) 22.Ce caHo
Ga jilt �z� t N 710 91. IZ7
6.Is(are)the wen IMPermanent or Temporary Signatl Ce ' well Contractor Date
n accordance
7.Is this a repair to an existing well', 13Yes or ONO u%GllSA NCAning C 02C.0I00 or ISA NCAC 022C.0 111al the 00JWell wasConstruction constructed
mad that a
rhrs is a,epai,;fill out known well conslrtrclion lrllarmaKon and explain the nature oflhe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the!back of this font.
23.Site diagrain 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 I GW-1 is needed.i 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: / .22 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
_ For multiple wells list all depths Ifdiffereall(example-3 a 200'and 2@1001
/ construction to the following:
10.Static water level below top of casing: OI`1 00 Division of Water Resources,Information Processing Unit,
{fivater level is above caslu&use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1417
11.Borehole diameter: 6 (in.) 24b.For Infection 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 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)i Method of test: Air Rotary 24c.For Water Suonly&Inleetion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.DisinfecdonityQe: HTH Amount: ®Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromiiental Quality-Division of Water Resources Revised 2-22 2016