GW1-2021-04192_Well Construction - GW1_20210401

N
WELL WATRUCTYON RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.wATER:zoNEs
Well Contractor Name FROM TO DBSCRlPTION` J
4448A R. ft.
' ft. IL
.
NC Well Contractor Certification Number j
IS-.OUTER CASING"for could-eeecd;welle:OR+LINERy d aetile
Cummings Developments; InC. FROM TO DIAMETER THICKNESS MATERIAL
Company Name _ +1 R• ft• 8 In. �C
e1 ,,q A 16i.INNER;CA3INGORTUBING eutiier�nd,closed=loo ;
2.Well Construction Permit#, !4 - 0 — V 1 c5 Z FROM TO DIAMETER THICKNEBg 1V(A9ERIAL'List all applk ahle well cbnstrucliwr perrnits 0 -IRe,County,Slate,Varlunre,e!c) R. n. in.
3.Well Use(check well use): ft. g,
[IndustriaYConimerciai
upply Well: 17.SCREEN'
ultuial =ftftft
DIAMETER SLOTSIZB THICKNEas MATERIAL
0MunicipaMblic Inermal(Heating/Cooling Supply) Residential Water Supply(single)
In.
13Residentiai Water Supply(shared)
18.GROUT<_.
ion FROM TO MATE., - y -7=7777=
ter SD 1 Well: ItIALpPy 0 R• 20 R Port Cement Pour
oring Recovery
n Well: R• R•
Aquifer Recharge Groundwater Remcdiation B• D'
LAquifer
ifer Storage and Recovery Salinity Barrier V19,',3AND/GRAYEL'PAGK
RROM TO MATERIAL EMPLACEMENT METHOD
Test ft
Drainage R. fL
erimental Technology OSubsidence Control R• &
thermal Closed Loop) OTmcer 20, RiI.LiNe LOG'attar!additional eheetsiif uecesaa "`i _
( p)
thermal Heatin Coolie Retuihi Other(explain under#21 Remarks FR To DEscRlrrloN error kamn somrock e n p%etc.
ft. ft.
:_`,to Weil(s)Completed: —�d Z� WeIIID# ft. 3 v % OC7
Sa.Weil Location a. ft.
Facility/Owner"Namc f J R R
Facility ID#(if applicable)
It0Y1 .W ft. tL
Phy�sica'Il,Address,CityMdZiP ft. ft.
e_ e I '21REMARKSi
County rP
!,d r3lq&j9a 1o777
Parcel Identification No.(PIN)
Sb-Latitude and longitude in degrees/minutes/seconds or decimal degrees: 14
(if well field,one lat%Iong is sufficient) I
a��� On • �tI� ]v y�� ��. ��^ W 22.Certifies
6.Is(are)the well(s)OPermanent or Temporary atur Ccnified Well Contractor Data
signing this form )heirhu cert(fy that the wells)was(were)constructed in accordance
7.Is this a repair;to an existing well:; OYes .or MNo xlth/SA NCAC 02C 0100 or/SA NCAC 02C,8200 Well Construction Standards and That a
f; Phis is a repair flu but known well construction infotyirhtian and explain the nature of the -Py of this recvrd has hear provided to rite well owner.
repair under#21 remarks section or on the back of this fo_nn.
23.Site diagram or additional well details:
r8.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 OW-1 is needed: IDdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
tpth lied: ._
SUBMITTAL INSTRUCTIONS
i For ulli w wellsl depth WON land u�fac"" (� (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulll�le wells Nsl ell d-/rths tJd�e exit,jexanrple-3@200'and 2@/001 ,
"' + F. n construction to the following:
10.Static water level tielowitop'Of caelll9 �o► (ft.) Division of Water Resources,Information Processing Unit,
lfwater love!is above casbrg nsr '+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) j
246.For Infection Wells: In addition to sending the form to the address in 24a
12.Well constriction method: Rotary above,also submit one copy of this iform within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to die following:
-
FOR WATER SUPPLY WELLS ONLY: r Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Rotary 24c.For Water Supply&Inlectlou Wells: In addition to sending the form to
13b.Disinfection � e:
HTH the address(es) above, also submit one copy of this form within 30 days of
�'P Amount: a OZ completion of well construction to the county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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