GW1-2022-07594_Well Construction - GW1_20220817

W,,LL%ONSTRUCTION RECORD (GW-1) For Internal Use Only:
E
1.Well Contractor Information: p
CHRISTOPHR WACHTER 14.WATER ZONES
`-
Well Contractor Name FROM TO DESCRIPTION
4448A
fit. fit. ' v
NC Well Contractor Certification Number 15.OUTER CASING(formulti-eased wells)OR LINER'if s licable
CUMMINGS DEVELOPMENTS, INC. FROM TO DIAMETER' THICKNESSI MATERIAL
+1 2 fit. 1 6 in. PVC
Company Name I
16.INNER CASING OR TUBING( eotherma[closed-loop)
2.Well Construction Permit#: 351Z) we--Z Z Z FROM TO DIAMETER THICKNESS MATERIAL
List a0 applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fit. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.'
J Geothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft. ft. in.,
IndustriaUCommercial13Residenfial Water Supply(shared) 18.GROUT .
IITI ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, -2b fit. PORT CEMENT POUR
Monitoring 13 Recovery ft. ft.
Injection Well:
fit. ft. i
Aquifer Recharge MGroundwater Remediation
19.SAND/GRAVELPACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG;attach additional sheets if necessary)
" N[color,hardness,soil/rock e, rain sim,etc.)
Geothermal(Heating/Cooling Return) _,Other(explain under#21 Remarks) FROM TO DESCRIPtt. h ft.
d!/
4.Date Well(s)Completed: — —ZZ- Well ID# /811 ft. q20 ft.
5a..Well Location:
� r�rl ft. fit.
tJ�t'1 L—►'Il1M_� ft. ft. �, .may ,� 6�.�.
Facility/Owner Name Facility IID#(if applicable) ft. ft. a
ILDIS
L..
BLV Z ft. fL AUG y i 022
Physical Address,City,and Zip--) p f q fit. fit.
Ak�C ftk_ _Q$RISJ.g L0 O Z Z 1 21.REMARKS { c V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) a 22.Certificati
3 0 1c1�� I N -110 �iZ • �5�, W p�
.�_
6.Is(are)the well(s)oPermanent or Temporary S' aturc ofCert' ell Contractor Date
By si ' this form,I hereby certify-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or EJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 pageto 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: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: QQ (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use-+" 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:
ROTARY above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rota construction to the following:
(' g 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) Method of test: AIR ROTARY 24c.For Water Supply&Infection 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: ���Z 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 Water Resources f Revised 2-22-2016