GW1-2022-10001_Well Construction - GW1_20221104

-WELL'CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
CHRISTOPHR WACHTER 14.WATER TONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft ft 7
n. n.
NC Well Contractor Certification Number 15.OUTER CASING Ifor malti-ened wells OR LINER 6 a n e
CUMMINGS DEVELOPMENTS, INC. FROM TO DIAMETER THICKNESS MATERIAI.
N ft. ft. 6 in. PVC
Company Name
r� 1L INNER CASING OR TUBING eothermal clmed-too
2.We0 Construction Permit#: ZZZO FROM TO DIAMETER THICKNESS MATERIAI.
List all applicable well non teri-iom permits p..e.(➢c,Co any.st o.. variance,etc) ft. ft. in.
3.Well Use(check well use): ft• f. in.
Water Supply We6: 17.SCREEN
FROM TO DIAMETER SLU9'SIZE THICKNESS MATERIAL
Agricultural OMunicipaltPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. In
:]Industrial/Commercial OResidenfial Water Supply(shared)
IS.GROUT
Irri ation FROM -TJO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ff C-Q R' PORT CEMENT POUR
Monitoring Recovery
Injection Well:
R. R.
Aquifer Recharge OGroundwaler Remediation
19.SAND/CR PACK Ka 'able
Aquifer Storage and Recovery QSalinity Barrier FROM TO TU I MATERIAI. EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage R. is.
Experimental Technology OSubsidence Control ft fc
Geothermal(Closed Loop) QTracer 29.DRILLING LOG albeh additional sheet.if necessary)
Geothermal(Heatin Coolin Return) Remarks)
Other(exlain under#21 FROM TO Dk:SCRIPI 10%lcnbr.aardsev,willeoekM1 ,grain sbm'etc.,
0 R. So R.
4.Date Well(s)Completed: Jo—I -Z2 well ID#
Sa.Well Location:
R. R.
M L W&uyyj R. ft
Facihty/owner Name Facility ID#(ifapplicable) R R •� s.vE•• s-•--
3109 Soyar �Ifl6�Il ft R __ '
Physical Address,City,and Zip 1 ft R. 7022
21.REMARKS
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,use lat/long is sufficient) 22.Cer'fifi
3G° �S. {)q N�q°2S•�SS w
6.Is(are)the well(s)OPermanent or .Temporary Signal Ccnified Well Contractor Date
'signing the form,1 hrtebve rerth that the well(a)war(weer)roactructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f Ihis is a repair.fill out known well construction information and explain the nature of the copy ofMu record ban 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 I GW-1 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: Yo (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q1009 construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,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
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ix.auger,rotary,cable,direct push,cic.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLFLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Suouiv& Injection 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: Z�Q Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depanment of Environmental Quality-Division of Water Resources Revised 2-22-2016