GW1-2022-09987_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHR WACHTER IC WATER ZONES
Well Contractor Name FROM DESCRIPT'ION
44 48A n. 10
A. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multl<uM welt OR LINER Ua 'able
CUMMINGS DEVELOPMENTS, INC. mom TO DIAMETER TmCICNEss MATERIAL
+1 ft. ft. 6 in. I PVC
Company Name
q p� 16.INNER CASING OR TUBING eotbermal clmed-loa
2.Well Construction Permit#: d I' t) LA.)t� IZ - D 1 In FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State,Variance.etc+) ft. A. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAME"TER SLOT SIZE THICKNESS MA I'ERIAL
Agriculmml OMumicipal/Public
Geothermal(Healing/Cooling Supply) Residential Water Supply(Single) ft fr in.
lndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irfi allon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Iln ft' Zo H• PORT CEMENT POUR
Monitoring Recovery R. R.
Injection Well:
(t. R.
Aquifer Recharge OGroundwater Remediation 19 SAND/GRAVEL PACK(Ba Uca a
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStcamwmcr Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTmcer 2R DRIL 'LOG attach additional sheets if ne
Geothermal(Heatin Conlin Return) Other(explain under#21 Remarks) FROM TO DESCRIPI ION(.,ma,hamhev,wiUm 1, ram Am,etc.)
I
Q 1 Z ft.4.Date Wells)Completed: 1 N —d2 Well ID# 152. ff. 1,10
ff'
Sa.Well Location: N. O.
R E U E� 'V i._
Facility/Owner Name Facility lD#(ifapplicable) R fL
3ay5 fm we-1\ ' _.A „SLoyterte-10d.276S0 R. ft.
Physical Address,City.and Zip rL R• IDScrRTa:ien Pr's sirlq Until
Gt,:l .a
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certifrca
34c IIJ14' N 79d tSlt W q-ag- aQ
6.Is(are)the well(s)OPermanent or OTemporary use i ell Contractor Dam
signing this form, I her ebv ,app that the wells) was(were)cowfouc rd in accordance
7.Is this a repair to an existing well: Oyes or ONo wirh ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Coustructim Standards and that a
/flhis is a repair fill out known well construction information and explain the nature of}6e copy ofthis reard has been provided to the well owner.
repair under#21 remarks section or on the back q(this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site derails or well
construction,only 1 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: L/ (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent)example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 199 (H.) Division of Water Resources,Information Processing Unit,
p,.ater level is above easing,use'++• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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.auger,ro(ary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gam) Method of test: AIR ROTARY 24c.For Water Supply&Injection Wells: In addition to sending the form to
pp the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH pmount:,dOz. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016