GW1-2021-00727_Well Construction - GW1_20210401

WELL C2NSTRUerTION RECORD(GW-I)' For internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
Well Contractor Name FROM TO aF$CRIPTiON
2, i9
• a iMR t
NC Well ContrectarCerfificationNumber 1S:OUTER-CASING formuN4WOd,Wella QR'L1NER'i�ia' 1a
Cummings Developments, Inc. FROM TO DUMVMR TMCKNFm MAWRiAL
+1 ft. 8 518 In- .188 G.Steel
Company Name 1C INNERCASING OR-'TUB NG Fdcre edit
2.Weii Construction Permit#: y 83 w ��Zt FROM TO DIAMF.TF.R TRlCK�t ■_ar^a
..a..... ..AIG.._. ,.:,-...,.......: ....,, .. ... , ....::j`, .w . u•�uuic,uc./ iR. Yi. - in.
3:Weff Use tcheckwa use): B- m
Water Supply Well- 17:SCREEN
FROM DIAMETER I SMT SIU I TRIMMMS LLyI MATERIAL
Agriculture! [3Municipal/Public fr. & in.
Geothermal(HeatinglCOOling Supply} Residential Water Supply(single) ft. ft.
IndustriaMommercial nResidenrigl Wntar R-MV-1..fay—AN _ _ -
-11trigabon mom TO MATERIAL Y EMPL-ACESt MrAIL+=V6i'AMOUNT
Mon-`l9 ater Supply Weil: 5mitt, 20 tic.
Port Cement Pour
Monitoring Recovery B, tt,
Injection wets:
A uifer Rech M B'
q � Groundwater Remediation .199AND/GRAVEL PACK►f' able �,
Aquifer Storage and Recovery Salinity Barrier
P.%RL& ^rr. _.
�`i 4"'.i�i i'iai UStormwater Drainage ft. !t. -- -
ExpensuctuaiTechnology Subsidence Control It, ft.
Geothermal(Closed Loop) Tracer 20:DRIL1JNG L OG atteeh addldanai cheetsll"
Geothermal(HeatinjVCooling Return) _ 0ther(explain under#21 Remarks FROM I TOL DESCR MON color, ft hardnem aomk Y eta
O ft. � a ;f
4.Date Weli(s)Completed:st_1Q-21 Well ID#_ 32, fw .��"' R'
511.Well Location: / Z,p d G
FacilitytOwner Nm a Facility 11Hi(ifapplicable) ft. fL
NO to N C- Hw�, 119 �. �.
Pbysicai A
ddres
s,City.and Zip p ft. ft.
874� -21.REMARKS :; 7 .7,
County Parcel Identification No.(PIN) `v'e551`1(9.V„6Zi
Sb.Lathhde and longitude in degreea/minutes/aeconds or decimal degree Ur+: ; °u o se-ca"O t
(ifwell field,one latltong is sufficient) 22.Certifrcatio
—/U
o,is(are)Inc wen(s)OPer'manent or Temporary of Certified Well Contractor Deft
By signing this form,I hereby certify that the well(v)was(were)constructed in aacordonm
7.Is this a repair to an existing well: ®Yes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill our known well construction information and explain the nalare ofthe copy ofthis record has been pravided to the well owner.
repair under 021 remarks section or on the back ofthis form.
23.Site diagram or additional well detailR:
S.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
c inctgte-.fitm_nnh,
driilem -------
�8142i'I'1'AQ:zhSTIYI:iCI'101YS
9.Total well depth ow land surface: 04 24s. For All Wells: Submit this form within 30 days of completion of well
l or multiple wells list a!/ll depths if di�'erent{arample-3Q200'and 2@100� construction to the following:
10.Static water level Mow top Of rasing: J (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casins use"r 1617 Mali Service eent?r.IaQleie`lt.NC 2?x99-!9vY
n
. kill.) 24b.For Injection Wells: In add t i i"�.....�..,......,.-_ � on to sending the form tothe address,in 24a
12.Well;coustruction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY LLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276".1636
13a.Yield(gpm) Method ofteath Air Rotary s®e,Anr o rr_s
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ZOO-7 ol completion of well construction to the ootmty haft department of the county
where constructed.
Form OW-1 Noah Carolina Department of Environmental Quality-Division of Wafer Resources! Revised 2-22 2016