GW1-2022-09976_Well Construction - GW1_20221104

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHR WACHTER 14.WATER ZONES _
Well Contractor Name FROM 10 UESCNIPI'ION
"48A fl. ft' / 1 S
V O O
NC Well Contractor Certification Number 15.OUTER CASING for mtM adwem OR LINER Rv 'nbk
CUMMINGS DEVELOPMENTS, INC. FROM TO DIAMETER THICKNESS MATERIAL.
.1 L ft. 6 in. PVC
Company Name .
r�.tl^� 16.INNER CASING OR TUBING thermal cloaed400
2.Well Construction Permit#: f�� - Wt° FROM TO DIAMETERI THICKNESS I MATERIAL.
List all applicable well,onstrurtion permits Ile.UIC,Cowry,Smte,Farimlre.e7)
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
Mom TO 1 DIAMETER I SLOT SIZE I'HICKNES.S MA'I'F.RIAL
Agricultural OMDnicipal/Public
Geothermal(Hesting/Cooling Supply) Residential Water Supply(single) ft R in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
Irrigation FROM4f:
TO MATERIAL EMPL.\GEM EN I'1tETHOD&AMOUNT
Non-Water Supply Well: zb fl' PORT CEMENT POUR
Monitoring �Rccovery fl.Injection Well:
ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery Salini Barrier M SAND/GRAVEL PACK ifs licable
O tY FAOM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage ft. rc
Experimental Technology OSubsidence Control ft h.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(aft ch addldoml sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Mom I ra.
ft. OR,tCRIPr10N leolar,M1artlnese,miVrvQ ry q ra B,ek.t
ft.
4.Date Well(s)Completed: �-13-Z Z Well ID# fl. fL
5a.Well Location:
M fl. rL
V l C f YR IDSU l4 D. D L e
VEeD
Faciity/Owner Name Facility lD#(if applicable) ft R
'5oa fl. flfl..
Physical Address,City,and Zip n. IDi Oral"�;..
D rcnV a 9- CkY(t53S133B 21.REMARKS
County Parcel Identification No.(PINI
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) r 22.Certi atio
b6. a02' N 7 9° 03 • Z-$a W
6.Is(are)the well(s)OPermaneut or OTemporary 1glaton,o ell Conhecmr Dam
8 ning Misform,1 hereby cn1i'lhat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONo 'th/SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
1f this it a repair.fill out known well construction information and explain the nature a e copy orrhb retard has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 page to provide additional well site details or well
construction,only l GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2@1009
construction to the following:
10.Static water level below rap of casing: ( (ft.) Division of Water Resources,Information Processing Unit,
If ware,level is above casing,use"- ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniecdon 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.augeq u(ary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 94 Method of test: AIR ROTARY 24c.For Water Supply&Ifliectlon 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: 9p k` completion of well construction to the county health department of the county
where consWcted.
Form GW-I North Carolina Department of Envicamomal Quality-Division of Water Resources Revised 2-22-2016