GW1-2022-10093_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Wall Contractor Information:
CHRISTOPHER WACHTER 14.WATER ZONES
Well Connector Name FROM TO I DESCRIPTION
4448A
R R r
NC Well Conoaaor Certification Number Su
IS OUTER CASING for T DIA aaed we1H OR LINER Hs DH
CUMMINGS DEVELOPMENTS, INC PROM To DIAMETEx THICKNESS MATERIAL
Company Neme
't ft' h- 65/a .taa G.STEEL
p (� is.DINER CASING OR TKING eoeTERthermal closed-loop)
2.Well Construction Permit#: JS 1� FROM To Duns THICKNESS MATERIAL
List all applicable,er/l conatmenon purnn (i.e.UIC,Coanly,State.Variance,etc) ft. R la
3.Well Use(check well use): h h. in.
Water Supply Well: 17•SCREEN
PROM TogAMETER SIATSITE TMCKNF84 MATERIAL
Agricultural OMunicipaVPublic ftR in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R I R 1n.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
hrl ation PROM TO MATERIAL EMPLACEMENT METHOD R AMOUNT
Non-Water Supply Well: R o20 R
PORT,CEMENT POUR
Monitoring Recovery R. h
Injection Well:
Aquifer Recharge ft. R
Aq B OGmundwarr Remediation 19.SANII/GRAVEL PACK fs icable
Aquifer Storage and Recovery �S 0mrovity ter Dr PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stomrwater Drainage R h
Experimental Technology Subsidence Control R R
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(a Is additional sheeH if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Rem PROM DPscm Nlrakr,h.ra.er rwuwrh mnae era.
4.Date WeB(s)Completed: -a� 72a. Well ID# 2 R b ft.
Sa.Well Location: it. ft.
ft. R
Feeility/Owner Ne a Facility ION(ifapplicabic) 'ram R R. _
ft. R \ate. J i (f
Physical Address,City,and Zip ( ) R R
to I Y S 8 SIjJ 2L REalARKSAF
Cooney Parcel Idendfica ion No.(PIN) Irti,Gtn',u:i,G
UPA
50.Latitude and longitude in degras/Woutes/seconds or decimal degrees:
(ifwell field,one boong is auificiem) 22.Certificad
3S0S9tWS ' N 776 a7, 37a ' W
6.la(are)the well(s)@Permaneut or ❑Temporary tgmturc of ad Well Contractor pre
tgaing this form,I here&rerl(fy awl the aell(s)tent(acre)cmDtructed in.dance
7.Is this a repair to an existing well: 13vea or JMNo wish 15.4 NCAC 02C.0100 w 15A NCAC 02C.0200 Well Construction Standards and that
If/hie is a repair,fill out known,veil cotutruclion informminn and erplatn the nature ofthe copy ofthis record hat been provided to the%ril o,emer.
repair under#21 remarks section or oa the bock 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-I is traded. 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: (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/la lin all depths ifdBerenr(example-3®200'and 2@1001
construction to the following:
10.Static water level below top of casing: I Lf/ (ft.) Division of Water Resources,Information Processing Unit,
rf,enter level u above eating.are +- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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. r m construction to the following:
sage tuy,cubic,dime[push,e¢.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)� Method of test: AIR ROTARY 24c.For Water Suooly&Iniection Wells: In addition to sending the farm to
/J/ _ the address(m) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: J W Z completion of well construction to the county health department of the county
where constmeted.
I.GW-I North Carolina Deputnn:nt ofEnvinannrental Quality-Division of Watcr Resources Revised 2.22-2016