GW1-2021-07426_Well Construction - GW1_20210921

Sa�E) L CC@l STT�iU�TI�N R ECQN Lqw--I) For Internal Use Only: -7T
1.Well Conttaetoe•Information:
t
Christopher Wachterj 14.WATER ZONES
Well Contractor Name $ FROM TO DES N
I. fL ft.
4"8A ft.
NC Well Contractor Certification Number ', �+� g�� ii� 15.OUTER-CASING(for taal9i-eased welts OR"LINER,ifs_ cable
Cummings?°,Developments, Inc., iC)� Ji,Qn FROM TO DIAMETER THICKNESS MATERIAL
Company Name \(iZ� +1 ft. ft. 61518 in. .188 G.Steel
16.1NNER C iNG OR TiJBING;fee6thiet5rialclnsedl-100
2.Well Construction Permit N: I FROM TO I DIAMETER I THICKNESS MATERIAL
list all applicable well canstradiott petmlti fl.e.1l1C,County,State,ilartonw,etc.) ft• H• In
3.Well Use(cheek well use): ft. ft. In.
17.SCREEN i _
Water Supply Weil: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipai/Public fe. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ft. tit.
IndustriaUCommt rcial Residential Water Supply(shared) c•1s:tpRouT _
._
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 20 fL Port Cement Pour
13Monitoring; 1311ccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if e' Gcable.
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test ; [3Stormwater Drainage ft n•
Experimental Technology OSubsidence Control ft. it.
Geothermal(Closed Loop) DTMM 20.DRILLING LOG attach additional sheets ifneeessa _
Geothermal(Hestin Coolin Retura 1 Other(explain under#21 Remarks FROM �T}O DESCRtPTtON coMr hardness.soit/rock a in aiz eta
ft- O ! ft i
! "4 7^u Well ID# ft.
4.Date Well(s)Compieted: it. o ,
-A 110-Ae-
Sa.Well Location: R' o
ft ft.
Facility/owner Name Facility iD#(if applicab % ft.
? � ft. ft.
germP icat Address,City,and Zip ( S '3 ft. ft.
h Q 'd�
Ub q2' 21:REMARKS_ ._
County Parcel Identification No.(PIN)
gb.Latitude and longitude in degrees/thinuteslseconds or decimal degrees:
(ifwell field,one lat/long,is sufficient) ! 22.Certificado
a N 8°S3'0 93 W 7_17-21
I`
6.Is(are)the well(s)MPermanent or nTemporary tgnature ofC e t ontractor Date
fining this form,1 hereby set?Ify tltallhe welts)was{were)constructed in accordance
7.Is this a repair to an existing well: MYes or x)No with 15A NC'AC:02C.0100 or 1SA NC'AC 02C:.0200 Well Construction Standards and that ae
If tits Is a repair,flit out brawn well construdihn information and explain the nature of the copy of this mcordhas been provided io the well owner.
repair tinder#21 remarks section or on the hack ofthisfarm.
23.Site diagram or additional well details:
&For Geoprobe/DPTor 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 G'W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: !I ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:,,._ OL 24s. For Ail Wells: Submit this form within 30 days of completion of well
liar muhlple welds list all Depths tfd&rent(cxammple-3Qa 200'and 2 t@100')
„ . � construction to the fallowing:
10.Static water level below top of casing: a2iJ (ft.) Division of Water Resources,Information Processing Unit,
If hater level is above casing 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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! Rotary to the following:
(i.e.anger,rotary,cable,dect push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service ibeliter,Raleigh,NC 27699-16M
Rotary r-~ '
13s.Yield{gpm} (/�,_,_,_ Method of test:Air � 24c.For'Fftiater SunDiv&Injection Wells: In addition to sending the form to
the address(es) above, aiso 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-1` North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I