GW1-2021-04187_Well Construction - GW1_20210401

Pr'ntFom
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 1C WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name ft,
4448A fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells°OR LINERI if a licable
Cummings Developments, Inc. FROM TU DIAMETER THICKNESS MATERIAL
+1 ft ft. 6 in. I PVC
Company Name
�p 16.INNER`CASINGORT[JBING eotheiaial closed=loo`
2.Well Construction Permit#: U 2C- Q 3 0 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): tt. ft. in.
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 26 ft. Port Cement Pour
Monitoring DRecovery
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier FROM
SAND/GRAVEL PACK M `MATERIAL
.
q g rY � tY FROM TO MATERIAL EMPLACEM ENT METHOD
Aquifer Test ®Stomiwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 206 DRILLING:LOG attach additional sheets If-iiecessetyl
FROM 'to DESCRIPTION(color,hardness,selllrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) R. f-,p ft. d; '
4.Date Well(s)Completed: Lt Welt ID# s`� ft• 5/S/� ft. •/
Sa.Well Location: it. ft.'
it. ft.
Facility/Owner Name �Facility ID#(if applicable) it. ft. � �•
17$Z`� �t�.i( bor�wal� 4.CY • �Q�/l,,l(LY�2�73c rt. ft.
Physical Address,City,and Zip ft. ft. U R 1 2021
1 9 8 Z3 �I r I S,7()3 21.REMARKS' f.
C—oun ty I Parcel Identification No.(PIN) f 3t40n Processing Unit
DWR,1C0T10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is s4ficient) 1 22.Certification,
34002- 07 S N 7L /5. 3 I- W Z-ts-Z1
6.Is(are)the well(s)OPermanent or Temporary S' trire of C 'fie' ontracior Date
Ir- signing this j rm,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ojthe copy gfthis record has been provided to the well owner.
repair under#21 remarks section or on the back oJ'this fora.
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 l 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: ��t% (tt.) 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'mid��2@100') construction to the following:
10.Static water level below top of casing: V (tt.) Division of Water Resources,Information Processing Unit,
if ivater 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 Resource's,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 SuDDIv&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: 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