GW1-2022-09999_Well Construction - GW1_20221104

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7VELL CONSTRUCTION RECORD (GW-1) For Internal K Only.
1.Well Contractor Information:
Christopher Wachter 14.WATEREONES
Well Contractor Name FROM TO DEscM"r
4448A rt'
R. I ft.
NC Well Contractor Certification Number
1S.OUTER CASING Me eulti•ased wells OA LINE ss
Cummings Developments, Inc. rnoM TO DIAMETER TWCIGiBY MAMIAL
Company Name
,1 ft. 3 2 it g in. PVC
16.INNER CASING OR TUBING( eothermal closed-moo
2.WeB Construction Permit Y: t?ID Ov FROM TO DIAMETER THICKNESS MATERIAL
Lill all applkahle hr/1 ron+mtrdan pmnlb ge.UIC Cbanty.$err,Parlance.etc.) O. fL In.
3,Well Use(chock well use): R. I R. in.
Water Supply Well: 17.SCREEN
Cultural FROM TO DIAMT'ICR SLOTSIZE THICKNESa MATERIAL.
OMunicipal/Public
Geothermal(Heating/Cooling Supply) ®Ruidential Water Supply(single)
Indu trial/Commercial OResidential Water Supply(shared) IS.GROUT
'Ill-rigation PROM TO I MATERI,AI. LMFWCLMENT METHOD&AMODNT
Non-Water Supply Well: o R• 20 R• Pat Ceroent Pour
Monitoring DRecovery tL R.
Injection WeB:
R. h
Aquifer Recharge OGroundwater Remediation
D(fei Ste 19.SAND/GATrL PACK Is
Aq rage and Recovery OSelinity Barrier rWN TO MA PAW. aaCIHOD
Aquifer Test QStoralwater Drainage R. &
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer DRUJJKG LOG otach additional It
Geothermal(Heating/CoolingReturn) r3Othor(ex lain under#21 Remarks) EOM To o m Leine.,meta sea.
rt. 2.S R
4.Date Wells)Completed: Wen ID# S R. R OL
Sea.well Location; Is R
PacWlylOwlotNama Facility lot(if applicable) R. IL
load R Nov 0
Pay.Wl Addtesa,CIA ad Elp
C'oc%I" °x217a6 ogoc,54 31. r ' ✓
Carly Pared Idmti&ation No.(PIN)
3b.Latitude and longkink In degrees/minuteslseconds or dechael degrees:
(if wag field,Our ha/long h suRjemnt) 22.CerRBcatio
36, /I • ZSD N -?4D 3mco w G ly/- 2.2
6.hisser)the well(s)OPermanent or DTemporary S' nuro ofCordfiW Contncbr Date
r form,/hneAv ca'((fy thug the well(s) cur(wwr)wastun,d in accordance
7.Is this a repair to an existing well: ❑Yes or ®No ulth 1Jd NCW 02C.0/00 or 15A NCAC 02C.0200 Well Caulructlaa Standards and lhar a
%Ihfe i+n repair,f]ll out knohm well emu0uetlnn lrtfamarlan and replvin the nah,re of/M copy ofthl,atxrord hm heal provided to dm he0 corner
,,pair under#21 resnarks$,pima or on the back oJ7Ms form. 23.Site diagram or additional well details:
8.For GeoprobelDPT or Cloud-Loop Geothermal Wells having the same You may we the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
driRed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &20 (R.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple hell,list all depths ifdiflenN(examplo-3Q200'and 2Q100')
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
K+wtrr level'ere shove caring use•'F" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in,) 24b.For Injection Wage: 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,salary,cable,diml puah,ear.) construction to the following:
DivhloD of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Smlce Center,Raleigh,NC 27699.1636
13s.Yield(gpm) , J :Method of test! err Rotary 24c. For Water Seemly&lislactio,Wells! In addition to sending the form to
/�,
9 the address(es) above• also submit one copy of this form within 30 days of
13b.Disinfechon type: HTH Amount: 0 y% completion of well construction to the county health department of the county
where Constructed.
Form GW-I North Cmolins Deparonem of linvironnrenml Quality-Division of Water Ruuuncs Revised 2-22.2016