GW1-2022-09975_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD GW-1 For Ltternel Use Only:
1.iv�eii Contractor Informatton: Print Forn
Christopher Wachter
Well Connector..... 14.WATERFibOM
ZO14ES
4448A ar e• TOZ rt• D sacmmoN
NC Wea CoatraeWr Covl6eulon Number ios B• IQ ft I�
Cummings Developments, Inc. 19.OUTER CASING formultiaasedweno ORLINER If, Ilnbls
FROM TO D"NILrgn THICKNESS MATERIAL
Company Nam° rt ft -3 % s in.
c� IL PVC
2.Well Construction Permit#• �.l�o — QOrQ(1 FROM TO
OH TUBING sothermd closeddoo List nil appfirahlr url/oonnrurtion pr 1O(l.e.VIC.Caen PIWM TO DIAM97TR TMCKNM MATERIAL
N.$atr.F 11.7s e.err.) ft tL In.
3.Well Use(check well use):
Water Supply Weil: rt' ft In.
Agricultural 17.SCREEN
�Municipal/Public FROM !Mn DIAM"' eigT 9laE THICKMM
Geothermal(Heatlog/CooOng Supply) rt• rt. ]n. MAT1wnL
IMResidential Water Supply(single)Ini atxiaUColnnrercial OReaidential Watm Su I (shared) rt' ft fin.
IDi anon PP Y(s 1t.GAOUT
Non-Water Supply Well; IROM TO MA
sM+wceMENr MEtxoD a AMauNr
Monitoring Recovery 0 rt• � ft Put Canard Pour
Injection Well: R
R
Aquifer Recharge Groundwater Romediation n' R
Aquifer Storage and Recovery ®Salinity Barrier 19•SAND/GRAVELPACf( cable
®Smmrwater Drainage
Aquifer Test MUM T R MA AL EMPLACEMENT METHOD
rt.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) ft ft
QTracer �
Geothermal Heatin Coolin Return) Other(ex lain under#21 Remarks FROM TO attsN.amtional sheets it micessa
DBscR....ONrcennrmrdsm,,avrom 4 amr
rt. rt. i
4.Data Well(q Completed: J�'z Wen]DO •!ft.
Ss.We11 Location: 5S2r , 1
T{> I �1�P.11t �a ,A ZI n' q ft L
e. to
1hmLp Nsmo - 1--'
Sl nl_ c� 5�k sr� �Ll✓�tn rat rt
ft .
••n.w.,tiseM,wy,and LP - . ...
o-q ll rt' ft.
P.REMARKS :, •.. �rt�
sooty Parcel Mortification No.(PM)
Sb.Latitude and longitude in deltraWadautalsecoads or decimal degrees:(limit gold,one bolting u'ufff i.,)
S° 111 N _79° of . ,v y 22.Cert1
l i
w z 6.Ic(are)the well(a)OPermanent or QTemporary igna or Cartmed
DMe
7.Ia this a repair to en existingwell: slaving lhlc fora.1 he/rAv crrl((y Ibsen nhr ax!!(s/oar(exre)caOU'utlyd is uccadance
IflAh isare air, ll tint kna ❑Yen or ®N^ v'i1A1SANCAC0?C.0100orISANCACO2C.menu.0200Well Cotulmollank.,dardrandlhata
P n ae well ea,,eeve!/nn lgfurma/lull and er lni/I IM1r nptl....ofthe ropy rd this record has been provided to d¢vxll
repair undel'#11 renarkr section or on the bock 0"Ithr fare,.
S.For GeoprabelDPT or Qoud• 23•Site diagram or additional wall details:
8.For Gee Loop(notirermal Wells having the same You may use the back of this page to provide additional well site details or well
4 only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled:
9.Total well depth below land surface- 12 0 SUBMITTAL BYa'I'R tCTIONS
Fannu/Ilple n•ells list all dep the ffdiffervnl(roan,"'-3e(0100'mid1®100•) (n') 24e. For AU Wen.; Submit this form within 30 days of completion of well
10.Stetie water level below top of using; - construction to the following:
/frwtrr learn is shove eosins;sett"+•' (ft.) Division of Water Resources,Intormation Processing Unit,
It-Borehole diameter: t) 1617 Mail Service Center,Raleigh,NC 27699-1617
(in,) 24b.For Injection
Rotary a In addition Co sending he form[e[he address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of wall
(i.o.sugar,riary,Cable,direct Push,eta) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, 'Underground Injection Control Program,
r'�
1636 Mail Service Center,Raleigh,NC 27699.1636
13s.Yield(gpm). Iz Method of test! Ayr Rotary
24c. Far W.ur sua.w&Injection Wells: In addition to sending the form to
131LDhbsilwilon typa. HTH the addresses) above, also submit one copy of this form within 30 days of
/
• Amount: 27 completion of well construction to the county health department of the county
where constructed.
Finn GW-1 North Camli,a Depamrcnt of Envlranmcntal Quality-Division Of Wa cr Resouxos
Rwkrd 2-22.201 fi