GW1-2022-09974_Well Construction - GW1_20221104

w
WELL CONSTRUCTION RECORD GW-1 Print Forr
For Internal Use Only:
1.Well Contractor information!
Christopher Wachter
Well Contractor Name 14.WATERZONES
4448A
FROM TO Daeen11p17ON
NC Well C 9
onnector Conification Numbor ft• h t
d r3�
Cummings Developments, Inc. 16.OUTER CASING farmuld-need ave0e OR LINER if,
Company Name FROM To nInMETER TNICILYEss MA7P2WL
.1 R. ft. 6 In.
2.Well Construction Permit#r W 2-2 - 6 16.INNER CASING OR TUBING(eothermal cloud4ou PVC
Lift all applicable rve//cwrrtrurrfo,pe m!trA UlC,CawN Smlr,4arlurtre.ale.) FROM IL TO DIAMETER TR/CKNEBS MA AL
3•Well Use(check well sae): D• 1"'
Water Supply well: R R In•
Aglicultural 17.111
❑MunicipaliNblic FROM TO mAMRTga UWSIa6 TRICYNEM Geothermal(Heating/Cooln Supply) R. MATERIAL
E ®Residential Water Supply(single)IndustxnUCommercial �Reaidengal Water Supply(shared)Irri anon 16 oAO1IT
Non-Water Supply Well: P1OM To wreaw, as3rLAceMelvr MErxoD AMouNT
Monitoring 0 O. m ft.
!q)ecgon Well:
Recovery Poncemant Pour
ft. R
Aquifer Recharge OGroundwster Remedietion D' D•
Aquifer Storage and Recovery ®Salinity Barrier 19.SANDIGRAVEL PACK
Aquifer Test ® FROM D TO b
Stomlwata'Drainage MA MBi'ROD
Expm'imcnrel Technology • ft
Geothermal(Closed loop) ®Subsidence Control D
(L
❑Tracer 20.Geothermal Hearin Co'l; Return) eaDAt TO a It
Other(explain under#21 Remarks D
4.Date Well a Co ,/ z molar .dlrrara au eel
() Depleted: 7 �I�% —z� �
Well ID#�__
m
Bar.Wdl Locetio8:
a. m
#, IL
�411—
Feeglb/Ownarl4amo
FeeiEty lDp(ifapplicea"
5 o a rcw)54 caw �1 l rt.
PhjOkII Addrew,Coy,and Zip
__ _ -.- i nil
C18 31 s a l 1 l., V 21.REMARKS
Parcel Identification No.(plN)
Sb.L thade and longitude la degrees/minutes/ueonds or decimal degrees:
orwall fhdd,one belong is sufficient)
37.
0 T3 . 9 -,,, i 2x Cardigan
N_79" la• 57! W
6.Is(Are)the Well(s)MPermanont or Temporary St tmoofC —16 -zz
of onlnotpr Dno
repair
an
or
/Jlp4lhuarrp ff//oul existing wall.
me•[/nOmarlan and Njr(am a5r nmme nJlke cvpY/WAAirmrofr2C.01 u pruvfdrdlAC0o the 2rCIve 0200WP11 (al"Imew61Sta ds,- andtaaCe
® /t NCAord has eeoor vi NCAC 03C.0300 Wdl Cwufrucltwr Stmidw'dv and l/ml a re/+air under 82l cassocks recliwi or wr the book of}hisfw'nr.
B.For Geoprabe/DPT or Cloud- 23.Site diagram or additional well details:
Loop Geothermal WeW having the same You may use the back of this page to provide additional well site details or well
colistmclion,only'GW-1 1a needed. indicate TOTAL NUMBER of wells drilled; construction details. You may also;rturch additional pages if necessary.
9.Total well depth below lands face: Z?✓✓ SUBMITTAL INSTRUCTIONS
For muldple sells list all depths lidiferent(rxamp/r-3Q300'and2®l00') tf2•) 24a. For All Wells;
/ Submit this form within 30 days of completion of well
10.Static water level below top of casing: h construction to the following:
ifnater level a above raring'ar"+" tit•) WDivision of Water Resources,Information Processing Unit,
11.Borehole diameter; 6 1617 Mail Service Center,Raleigh,NC 27699-1617
pnJ 24b.For Infection Well.; In 12•Well construction method; Rotary
above,also submit one copy of this form within 30 daysf completion of well
(i.e.cclar,rotary,cable,direct push,etc.) construction to did following:
FRASUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Progreso,
1636 Mail Service Center,Raleigh,NC 27699.1636
pm) Method of test: Air Rotary3 di e. Bo Wet SL 1 A 1 i fi i! II : !n addition to ending the forayto
fion type: HTH Amount: d/C'i. the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Foim GW-1 North Carolina,Department ofEnviromnomal Quality-Division of Water Rcsaurca
I4wnad 2-22-2016