GW1-2021-07371_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter
Well Contractor Name FROM TOI D//E��SCa1PTtom
4448A
ft. ft. V i S 77
1 1
p
NC Well Canhnetor Cortifieation Number S�C ft. ft. IS @ 21
r g1(o� *-OUTER.CASING-adi mu1tL¢nseil;wegi oR1INRRfi d'--" celile ,
Cummingsbeveiopments; Inc. �,5��e FROM To DIAMETER THICKNESS MATERIAL
Pay \�� �� +1 fG ft. S In. PVC
Company Name z
Q 16:INNER`GASINGORTUBING('eotfiermaliclosed=loo ►y _ ':'
' z
2.Well Construction Permit#:_LA)a O- -7 ' FROM TO DIAMETER ] THICKNESS MATERIAL«»
List all applicable;ivell construction permits(I.e.U1C,County,State,Varfunre,etc) ft• n. in.
3.Well Use(check wen use): ft. ft. in
Water Supply Well: 17.SCREEN
Agricultural 7 FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL <
13Municipal/Public R. ft. in.
Geothermal(Heating/Cooung Supply) IlResidential water Supply(single)
ft.
lndustriaUCommercial ft. in.
Water Supply(shared) _
18aGROU7,;,
- Irrigation FROM To MATERIAL EMPLACE RENT ME91535 @ AMOUNT-
Non-Water Supply Well: 0 R• 20 n• Port Cement Pour
Monitoring : Recovery fL it
Injection Well:
Aquifer Rcchar H• &
q ,g' ®Groundwater Remcdiation
Aquifer Storage and Recovery Salini Barrier -19.SAND/GRAVEL,PA- ,aU" nble•� --
tY FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stoumwater Drainage R• ft.
Experimental TechnologySubsidence Control
Geothermal(Closed LOOP) 13
OTracer S0:'DRILLING:L'OG:attach addlndeal ibeetii ifitieceseA,
Geothermal He- n Coofin Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardnesLzoIjjra&tyjpj6 vain size,eta
4.Date Well(s)Completed: r23'2( prep IB# 27 ft. 6�
52.Well Location:�y R. yZd it.
0 a d JL '�Q�� ft. ft.
Faeility/Ownor Name Facility ID#(if applicable) R- %
_via u fL
Physical Address,City,and Zip % ft.
0—n p q R 916q 1 i o 3 -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one hinong is aufficfcnt) 22.Certiflca
6.Ware)the weil(s)oPermanent; or Temporary Signe Ccrtificd Well Contractor to Z I
BY signing
lhts jotmh,I heiebv certyy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JMNo with 1SA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards mid that a
/f this is a repair,f li out known well consusmtion btrannation and explain the nature of the ropy of this record has been provided to the well owner.
repair under 021 remarkrsection or on the back of this form.
23.Site diagram or additional well details:
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
construction,only 1 GW-I is needed.i Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled.
/ 2— �t, SUBMITTAL STRUCTIONS
9•Total well depth below land surface: (J IN(11•) 24a. For All Wells: Submit this form within 30 days of com letion of well
For naahlple hells list all depths ijdI erent;(bxmnple-3 rr 200'mt Z construction to the following:
d 2@1001 p
'
10.Static water level below top of casing: (ft.) Divieton of Water Resources,Information Processing Unit,
/l avatar level is ahaim cashh&liar"+^ 1617 MeI�Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction 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 WELLS ONLY: Division of Water Resources,)Underground Injection Control Program,
I 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)i Method of teat: Air Rotary 24c.For Water Sunnty&Inieetlon Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfectiontype: HTH Amount: �O completion of well construction'to the county health department of the county
where constructed. III
Form GW-1 North Carolina Department of Enviromnontal Quality-Division of water Resources Revised 2-22-2016
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