GW1-2023-01487_Well Construction - GW1_20230209

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'ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
A.Well Contractor Information:
CHRISTOPHR WACHTER 14.WATER ZONES
Well Contractor Name FROM 10 DESCRIPTION
4448A
C Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a able)
CUMMINGS DEVELOPMENTS, INC. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. I'/ fr. 6 in. PVC
Company Name �O
t� ��y 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1AJ zz—QO t 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. I in.
Water Supply Well: 17.SCREEN
FROM TO ULU1ra F:R SL09'SI%E THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
'Irrigation FROM I TO M%I f.R AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ?O ft. PORT CEMENT POUR
Monitoring 0 Recovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Q Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain si r,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) k `D ft. /
4.Date Well(s)Completed: 0049011W Well ID# /0 fr Z�p ft C L
5a.Well Location: J z—Z—ZZ ft. ft. [ A
�Aeau�. k, 'I I,LLC ft
Facility/OwnerYame I' Facility ID#(if applicable) ft. ft. �r�
7%1-1 A It Ism ]emu l�1 CL [��li'l� � ft. ft.
Physical Address,City,and Zip
Orao`Q� gBS�a�1 n gag 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laatt/lonn)g is sufficient) / I 22.Ce ca n:
6.Is(are)the well(s)o Permanent or/ Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constriction 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 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: Ql0 0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200?'and 2@100') construction to the following:
10.Static water level below top of casing: J / (ff.) 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 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:
(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
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&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 zoe l 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