GW1-2022-10092_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD (GW 1) Print Form
For internal Use Only:
I.Well Contractor Information:
CHRISTOPHR WACHTER 14.WATER ZONES
Well Contractor Name mom TO DEsclurrn�ole
4448A R. R' VA C 7(0
NC Well Contractor Certification Number ft ft. % q';� 'I '05�'
15.OUTER CASING for mui aced weW OR LINER if a Ileable
CUMMINGS DEVELOPMENTS, INC. mom TO DIAMETER THICKYPss MATERIAL
Company Name .1 R. h 6 In. WC
3 C 1 A F z Z Is.INNER CASING OA TUBING eotbermal dosed400
2.Well Construction permit#: J u V PROM TU DIAMETER TNICKYE33 MATERIAL
Linall app/iruA(e,wllrmrrtrurtiou prrmrerQ.e.U/C,Cwnrry,State.Puriam�e,rtr.) M1 ft. in
3.Well Use(check well use): ft. fL Ia.
Water Supply Well: 17.SCREEN
Agdcult=l ❑MunicipaVPublic R. in
PROM TO DIAMB'1'OI 81Arro1rE THICIAM AIATP.aIAL
R.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
R. at. la
lnduslriaVCommercial QResidmtial Water Supply(shared)
Inf lion iL GROUT
PROM TO MATERIAL EMPLACEMENT MCENODA AMOUNT
Nan-Water Supply Well: d 'L ft' PORT CEMENT POUR
Monitoring Recovery IL 6
Injeetioe WeO:
Aquifer Recharge OGroundwater Rentediation
Aquifer Storage and Recovery Salinity Barrier 1P•SAND/GRAVEL PACKIf leable
PROM Aquifer Teat OStonnweter Drainage ft. TO IL
"ILACYMLWMaTHOD
Experimental Technology Subsidence Control rt, M1
Geothermal(Closed Loop) OTIRcer 20.DRILLING LOG altsch assam aal abuse if neeeau
Geothermal(Heating/Cooling Return) Dollies:(ex lain under#21 Remarks) FROM TO DWRI"10
gN Imbr Yardaear.tl0rxe e, Ndn,ek.l
4.Date Well(s)Completed: 1 �9- a7` Well ID# R• fL
/5a.Well Location:
ft fL
1/ NaM=P Facility to#(if applicable) R. fL Kim/ e
I ft. rL
Pt aiul Address,City,and Zip ,, / R. ft.
511I r� 21.REMARKS
County -� 1 .✓
Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field.one kylong is 22.CerllDcati
/
1 s t N (^ r d r y• / q/'
3 G L'0Q t� I (0 V
6.Is(are)the we11(e)oPermanent or OTemporary Sigmt of Wall Contractor Dam
7.Is this■repair to an existing well: B .igntn is farm,I her'ebv crnh�that the xrll(r)a,D f eery)com r",d b,.,,dancr
Yes or ®No 'tA NCAC 02C.0100 or/SA NCAC 02C.0100 IV,11 Cbmu merlon Mandwds and that a/Jlkir it a rrpatr,fill aul Moan tun//cmisOvcGon informa/i m and erplow IM auunr of the oflbis record has her,,provided to dw nrlf oxrrer.
repair under#11 remarks section or on the back oflhis,lorm.
23.Site diagram or additional well details:
R.For GeoprobetI)PT or Closed-Loop Geothermal We)h 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 attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
S,Total well depth below ffdl$rrr,,d surface:" (R.) 24a. Far All Wells; Submit this form within 30 days of completion of well
multiply xrl/s/W o!/drplu%
potnr(rxamplr-i tLd1 'mid lQ l00'1
construction to the following:
fl
ifxnter loeve(8 uhoir caring,use.Statice water level below top of casing. _ (B.) Division of Water Resources,Information Processing Unit,
••+^ 1617 Mall Service Center,Raleigh,NC 276#0-1617
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,mmry,cable,direct push,dc.) construction to the following:
FOR WATER SUPPL�WE LS ONLY: Division of Water Resources,Underground Injection Control Program,
.r�JJff 1636 Mail Service Center,Raleigh,NC 276".1636
13a.Yield(gpi Method of test: AIR ROTARY 24c.For Wafer SRooh&IndeeHon WN s: in addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: /Zi Z completion Of well construction to the county health department of the county
where constructed.
Form GW-I North Camilla Department of Envimnmcmal Quality-Division of Water Resources
RuvuM 2-22-2010