GW1-2022-09972_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD GW-1 Print Forn
For hxtemal Use Curly:
I.Well Contractor Information:
Christopher Wachter
Well coital Nemc 14.WATER ZONEg
PROM TO
4448A R' ti I S 0 I Z Q l
NC Well Conhyctor Corifintion Number R• R
Cummings Developments, Inc. IS.OUTER CASING fee mull nand we OR LINER its cable
FROM TO DIAMETER TRICKNUS MATERIAL
Company Name rl R. R,
r-T 8 in.
2,Well Coestruction Perini#: UBING(_ li�l�r'�- �'3' / Ill INNER ING OR T eotharmal cloned-im PVC
Lire rd/r)pp(hahlr well MATER
FROM T°ronr/rurrion pe IU DIAMETER TmCReESS IAL
hr.UIC,County.stair.Ymfanrr.err.) at,
3.Well Use(check well use): a in.
Water Su fL R• ie.
PPIY Well:
17.BCREP.N
Gembelemal OMunicipidl Nblic PROM TO DtAaR71R atATTai2E TRICTCR869 MATERIAL
Geothermal ramie g/Caobng Supply) ®Ruidential Water supply(single) R R. �
IndustrlaVCommercial PP Y( S R. R. In.
OResidential Water Supply(shared)
Irri anon It,OROVI'
Non-Water Supply Well: PROM To Al BMPWCIJ116NTMEiHOD&AMOUNT'
Monitoring0 D• 20 ft.Recovery p01r
Injection ell: rL R
Aquifer Rocharge ❑Groundwater Rcmediation R• ft
Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ■ le
Aquifer Test FROM TO MATERIAL
❑Stomlwater Drainage fr, & EMPWC TMETRoD
GeoExpthermal
( Technology ❑Subsidence Control
Geothemal(Closed Loop) R• rt.
❑Trrecer If
20.DRILLING LOG attach addltioAdditionalaheab
Geothermal Hearin Ralam) Other(ez lain under#2l Remarks) FR°M 'to DEFCRII'TtON lesion haraveµ WVrara MrW,ere.l
o R. rJ R.
4.Date Well(a)Completed. 7` -ZZ Well HI# rt.
l_l
rrS&'Well Location: I •�� R.YM4
FacIDtr/ =Name °• tt .,�. /
n Fail IDY(if applicablcl
�I� AT
PhyPusid Amur,Car,and IL
' -iXI08?i9ta 1 ) :1.REMAKES
Coamy —
Parcel Montlflalion No.(PM)
Sit'Ladiade and longitude in degrees/miuutes/aeconds or dechnai degrees:
(if"it fold,our laillul k eufflricnt)
IL , �G'ir ' 22.Cards"
6.Is(are)the WOU(a)imPemvnnent or Tem era
❑ p ry gnatum ml ad Wall Co I all Dino
7.Is this a repair to an existing well: ❑Yet or ®No r gnine ids faax.1 barbv ce"Ify'hat the well(') WUS(were)Connru°rE in accordm,ljtbu O a m/ada re our knoay w-A cmuhvNlort 1�n rlon and esF/aui the nanva aflhe roGY 15A NCAC 0 C.0100 0Q 1 ANC Ue02C'alder Wf11 COIpINcrion P,ulsal'd,and that 0 repair under#21 remarks reGiOn Or ou the bast OJ7hlrjmTn. has S.For Geoprobe/DPT or Qosed- 23.Site diagram or additional well details:
construction,on] 1 G W. Loop Gmtbenal W�having the same You may use the back of this page to provide additional well site derails or well
y 1 is nceded. Indicate TOTAL NUMBER of wells construction details. You my also attach additional pages if necessary.
arises:
9,Tolal weB depth below land surface: ZYO SUBMITTAL INSTRUCTIONS
For multiple%wit,lilt alldep'hr lfdiivrvn'(eranr (v- (fr') 24a. For A
F 3�aon wrdl®lod�) 1 Wells Submit this farm within 30 days of completion of well
10.Static water level below top of casing;_ .`I construction to the foflowing:
bruvrn.lawl u,Oboverarin&na'i•• (fr.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 2761
(in.)
Rota 24b•For Injection Wry: In addition to sending the form to the address in 24e
12.Wen coutruetlo ry n method: above, also submit one copy of this form within 30 days of completion of well
(Le.aall Mary.cable,dii push,eta) construction to the following:
FOR WATER aural WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
13a,Yield(Spur) _ Method of test: fir Rotary
24e.For Water S 1 &Initiation Wall.! In addition to sending tha form to
136.Dlaintection type; HTFI the address(es1 above, also submit one copy of this form within 30 days of
Amount: /Y0 2 Completion of well construction to the county health department of the county
where constructed.
Form GW-I North Camlina Dopenia mt of ervironnumal Quality•Division of Wamr Ruourcuy
?,0V15cd 2-22-2016