GW1-2022-10006_Well Construction - GW1_20221104

Print Form
WE4,L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 7
CHRISTOPHER WACHTER 14.WATER ZONES
Well Contractor Name mom To I DESCRIPTION
4448A p
NC Well Contractor Certification Number 8 S R 2 R got- 0 7
15.OUTER CASING for mameased w OR LINER Uf s bla
CUMMINGS DEVELOPMENTS, INC FROM To DIAMETER THICKNESS MATERIAL
Company Name '1 fi. ? ft' 65/6 in. .188 G.STEEL
514014 7 16 INNER CASING OR TUBING eo[hermal clmedmp
2.Well Construction Permit 0: t 1,1 L raoM TO DIAMETER THICKNESS MATERIAL
List all applicable wetl construction permit/(i.e.U1C.County,State,Variance.etc) R. R I fa.
3.Well Use(check well use): R. I R. I In.
Water Supply Well: 17.SCREEN
I'ROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public f. I R. I In.
Geothermal(Heating/Cooling Supply) JaReaudiential Water Supply(single) ft. I ft. I.
Industrial/Commercial QResidential Water Supply(shared) I&GROUT
IIIi ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- Zo R PORT.CEMENT POUR
Monitoring Recovery ft. R
Injection Well:
rL R
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Ba e
Aquifer Storage and Recovery OSBlinIty Barrier FRAM TO MATERIAL EMPLACEMENT METHOD
Aquifer Tat Dm Storwater Drainage IC R.
Experimental Technology QSubsidence Control fi. R.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG Ismail,additional sheets Boeceau
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) mom to DESCRIPrwN town.e.,aaem,teivrveE type,tram dra,etc.)^^11 R.
4.Date Well(s)Completed: -oC�Well ID# R. S' R.
5a.Well Location: cr T
R.
f` R
REe
Facility/ e� Facility IDp(if pplip cable) R R.ft. Ft NOV 0 -s
G�.Cl 2022
R. R.
Po A/dd}res�a�C�ily',�avd ZW qI rll(,�/�ip JIJ-v(y
�
lM 1V.L1'1� lal 21.REMARKS Ipbra4klPr^^ +,
v1 ,13,s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iavlong is sufficient)
fficient) ) 22.Certiftcatio
3LD07 .7S`1 N � I ° Iq• 1l7 W to- q -aa
6.Is(are)the well(s)OPermauent or OTemporary been ofCe 0111 Contractor Dare
g this form,/hereby certly that the ael/(s)arts(wren)romuucted in accordance
7.Is this a repair to an existing well: 13Yes or JUDONo with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Conmuction Standard,and that a
/ftha it a repair,fill out known writ contraction information and erplain the nature fthe copy of-rhis record has been provided to the well owner.
repair under 821 remarks section or on the back ofth farm.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also arach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
/(�
9.Total well depth below land surface: /g O (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifereat lexample-3Q200'and 2@1001 construction to the following:
2
10.Static water level below top ofessing: U 7 (ft.) Division of Water Resources,Information Processing Unit,
/f water level u above rasing,use"+- 1617 Mall Service Center,Raleigh,NC 2 7 6 9 9-161 7
11.Borehole diameter: 6 (in.) 24b.For Infection 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 fallowing:
(i.e.auger,rotary,cable,direct pmh,nc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /4?- Method of test: AIR ROTARY 24c.For Water Supply& Infection Wells: In addition to sending the form to
�J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ` completion of well construction to the county health department of the county
where constructed.
From GW-1 North Carolina Department of finviromiu n al Quality-Division of Water Resources Revised 2-22-2016