GW1-2023-01447_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
' 1.WA Contractor Information:
CHRISTOPHER WACHTER 14.WATER ZONES
Well Contractor Name FROM To I DFSCRifJ1ON
fY. ft.4448A '
rt. rt.
NC Well Contactor Certification Number INC15.OUTER CASING for multi-cased wells OR LINER if a livable
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 It. 3 fL 1 6 5/8 in- 1 .188 G.STEEL
�{ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 53+ v� V 1,im"��,�f2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in. 4--
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Agricultural
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt. 01D ft. PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [JStormwater Drainage fL fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DE.SCRIP9'ION color,hardness,soft/rock tv e, rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) 0 ft, S'u It. 30;
4.Date Well(s)Completed: ( `l - Z L Well IDff ft- D• ck
5a.Well Loc n: ft. ft. `�3a U :i V
C A/„ J fL ft _
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Facility/Owner Name Facility ID#(if applicable) ft.
L� Is. rt. Prr c3wN2 n:
d fek2i t Intc;lr�:►�
PAmoce-
I Address,City,and Zip
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I ca 20 L 11O t 1 A(f 21.REMARKS
County Parcel Identification No.(_P`IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iffwell field,one Iat/long is sufficient) 22.Certificati
o 1 y, a 1L i N `III 1 S, U Q'`�3 W
II -II -ZZ
6.Is(are)the well(s)oPermanent or 13Temporary Si of i led Well Contractor Date
ping this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 19No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 1 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: 1.D� (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiQerent(example-3@200'aanndr,2@100) construction to the following:
10.Static water level below top of casing: ✓`r' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Iniection 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: u Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016