GW1-2022-09977_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD GW-1 Print Forr
, For hrtemal Use Only:
1.Well Contractor Information!
Christopher Wachter
woil i;u=nor Name 14.WATER 7ANE8
4448A
FROM TO DEFCRI%'ION
rt. rt
NC Wen Caoaaetor Cattlfiratioo Numbor f. ft
Cummings Developments, Inc. 16.OUTER CASING for muln.c.s.d wells OR LINER if n6k
FROM TO DIAMETER THICHNEEE MATERAL Company Namn a1 f4 I ft. 6 126
PVC
2.Well Construction permit#: I�-=Z � - C3U� Is-INNER CASING OR TUBING(rtigmal eloaeddoo L/1,ull appllrabinvrllronarrllNionye !i FROM TO DIAMETER
f e.WC.Caulr,y,Stan.Far'bmre.Plr.) fr. THICKNESS MATERIAL
3,Well Use(check well use); D. ta.
Witter SuPAYWell: D' R ID.
17.SCREEN
AgriculturalOMunicipaVpublic FROM TO DuaurEa aLorelzE
GeOthermal(HCooliag Supply) ®Rnideninl
TNICI(IVEBa MATEIAL
LrdustriaVComnercial Water upp1y(sin(single)
OResidenfiel Water Supply(shared) in.
Im non
Is.GROUT
Non-Water supply well; FROM To aursmAL EMPWCEMENTMETHODR AMOUNT
Monitoring D O• 20 R. Pon Oanam Pour
Injection Well: �Ov� ft
R
Aquifer Rocharge OGroundwator Remcdiation . h. R
Aquifer Storage and Recovery OSalinity Barrier It SAND/GRAVEL PACK
Aquifer Test FROM TO MA
®Smmrwater Drainage R rL EMPUCEMENT METHOD
Geothermal al
OSubsidence Control
Geothermal(Closed Loop) R' R
OTincer 20.Geodhermal Hearin Conlin Rt1pRa) FROM LOfi atta4 It
Other(ex lain under#21 Rwuka TO DIifCWprt mint ratio rdureaM
4.Date wall(s)Co IL S 2
mplated: `I a 9 A wwell H* 1r2 e. R.
Sm.Well Location:
Z6
1i
Blf_] r1'0
Name
St. R. 1J
Fa4lity lDa Of+pMkable) R R
�Il Ko5 t l na ze1 �� �d ^ nit
PhYaloal Addition,City,and Eip � �1-•�dll, rt �
rt.
Cowry Q�Oi1 21.REMARIIS
Parcel Identifica0on No.(PIN)
Sb.Lasltde and longitude in degreea/miautayxconda or decimal degrees:
lIf volt gold.am IsUb mit u,MiB i m)
3(o°LG • 0_ a '
e N
6.Is(are)the )+y;,p
well s ll�e P ry
( Permanent or TemOra ��! eruro of crafted Well Contnepr
Dace
7.11 this a repair to an existing well; OYes or ®No By Signing/A(1 folm,!hu,mbv crrilry,Aal Ike aril($) I us(WHIP)eoe,rll•,eMd in b islllA u repuiq�l(out knoaN,vr(I eaadOa',lnn(nfm'nmlion rand erplain,hr nM Cr do drAFC4CA h t eCCO,'denCP
aril a,00 WPII Cmulruetlon P111dmds and that a
repalr Milder#2/renuvktaeclia,or ar the back oflblrform. ,ure a/IkP co Y rl lh ireord h h Or
8.For Geoprobe/DPT or Qosed- 23.Site diagram or additional well details:
Loop Geothermal Wens having the same You may use the back of this page to provide additional well site derails or well
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled: construction details. You my also attach additional pages ifnecessary.
9.Total well depth below land surface: 7 SUBMITTAL INCTR CTIONC
For IIIM!#(/IrN•PIIT I(rl al/dPPIAt/fdyerrnl(PYpNIf/e-.t (ft) 24a. For AB Welts: Submit this form within 30 days of completion of well
612o0'm,d1®/009 10,Static water level below top of casing: construction to the following:
17,wrrr level is alavr cacin�Mx"+" (ft.) Division of Water Reaour
]617 Mail Service Cent rlRalel�tion pmouMbg n1
Raleigh,NC 27699 6117 4
11.Borehole diameter: 6 (In,)
246.For injection Wr6 ; In addition to sending the form to the address in 24,
12.Well conetructian method: Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auyNr,romrg cable,dirett push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY- Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: Air Rotary
24c.For ViLakr Supply a- s-r--.i- - -- . 1.addition to seeding the form to
13b.Disinfection type; HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: A.,7 7 completion of well construction to the county healthdepartment of the county constructed.
Form OW-I North Carob a Depamna,t ofnnvinnmantal Quality-Division of WaWr Eaaourcu
14vked 2-22.2016