GW1-2022-07640_Well Construction - GW1_20220817

WELL CON�TRUCTYON RECORY) Gi�V-1 r �aPrintForrr
For Internal Use Only:
1.Well Contractor information:
Ch17stWpher Wachter
well contractor Name - :.•:• -,_
RROM 4448A TO DROCS!"ON
e.
NC Woll Contractor Cordflcation Numbor d' ft,
Cummings Developments,. tnC. 15.OUTERCASING formulH=carled.weW OR<LIN>i
FROM TO DIAMBTLR THiC141165a'�• NA4FdtiAL
Company Nome •t R. ° ft. g In. PVC
2.Well Construction Permit#: « D 4 16.1NNER CAGING OR-TUBING eottiei oial:¢loaed�loo .
LIsI all opp/irah/e well s onahweylon permb(i a UIC,County,Sf rfe,Variance.etr� FL EOM TO D1AMt3788 T8ICt4Vli86 MATn1iiAL'
3.Weil Use(check Wenuse): �
im
ft. AL In.
Water Supply WpB; ?.SCREW
3ASriCultural RROM TO DIaMBTaR aLOT812E �'-
�Municipaypublic TxtcltNxss MATxwAI. N
Qeothermal(Headowcooling Supply) WResidential Water Supply(single)sin le) e. R. in.
lndustriayComnterciel g ft it. In
Residential Water Supply(shared)
tion 1S..0ROUT.;
1—ter SmPply Well: TO
naoM
r.ACPa+mNrNtarxoa AMouNr
Monitoring Re overt' 0 R' 20 It. Pon Cement Pour
action ell: t1. L
Aquifer Recbargo ®C,mundwater Romediation %
Aquifer Storage and Recovery [39olinity Barrier 19.SAND/GRAVF.Is PACK a at61e
Aquifer Test FttoM To asaTERur, r Me�riloti mtwater Drainage ft tt,
Experimental Technology DSto�SubsIdence Control
Geothermal(closed Loop) �7 Ubsi e, &
20:DRILLINGI:OG atdichad tdoealAwatiff'"- -- `
Geothermal Hearin Coolin Return) Other(ex lain under#21 Remarks ream To
D� IPTION actor trnNeam rdl/rodr alai:
4.Date Wcll(s)Completed: -7—15 -Z'Z Weu ID#
f
59.Well Location:
�� I.E..N r D• ft � :�� �.
Fac71ty/0wrmrNamo Facility lD#(ifapprae) '
/ libl R• R.
Elan & m
Physical Address,Cay,ana arp
l ASWP l 1 004.1 00 21.REMARII6, R• ' 9 t Urt4
county
000cogq A.:- -
Parcel idontification No.(PDT
Sb,Latitude and longitude In degrees/minutp/seconds or decimal degrees:
(if well field,ono lai/long is sufffdat)
22.CertiBcad
6.Is(are)the w s eit() Permanont or Temporary Si at of C Wall Connector Date
7.Is this a repair to an existing well: E3Yes or ®No sign fora)'.'helrbv ce"10'hat the weft)tuns(were)wnsaardrd In accordance
(fthls k a repah:f gout known wa11 comirmcdon lgforma!'on and explain the nalnrr oflhr SPY 4l rh��cord has hear Provided M Ce well o02C.0200
0 W011 Consimetion Standards and that a
repair under#21!+t'mm*smilon coon thobackofthlsform.
23.Site diagram or additional well details:
9.For GeoprobelDPT 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 OW-1 is needed,:Indicate TOTAL NUMBER of wells construction details.
Had: You may also attach additional pages if necessary.
dri So RUBMITTAt.nvamRRIMONS
9.Total well depth below land surface: (�)
Bar multiple uric fist all depths(fd&*ren'(rxan plc-9�200'arts 2®1001 Z4a• For All We k Submit this form within 30 days of completion of well
K construction to the following:
10.Static water level below top of casing:_ (ft)
(fiavfrr level Is above easily aw"+^ Division of Water Resources,Informallon Processing Unit,
1L Borehole dlameter:6 (�•)
1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Infection We1L: In addition to sending the form to the address in 24a
12.Well constrncdon method: Rotary above,also submit one copy of this form within 30 days of completion of well
0-auger,rotary,cable,direct pails,arc.)' construction to rite following:
'>?6R AT>(R SUPPi ELLS ONLY: Divlslom of Water Resources,Underground Lrtitcell Content Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
132.Yield m J` 1
�.) Method of test. Air Rotary 24c.For Water 8aenly Inieetien l+Jan
In addition to sendina rHTH the address(es) above, also submit one copy of this form within 30 days of
13b,Disinfection Amount: d� completion of well construction to the county health
where constructed. depaulment of the county
Fenn OW-1 North Carolina Doperunent of Environmontal Quality-Division of Wator Resources
Rctdscd 2-22 2016