GW1-2021-02016_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD(GW4) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER ZONES
FROM TO DEBGRIPrlo
Well Contractor Name
4448A rc. rt. c/ .� J
rr. tr.
NC Well Contractor Certification Number 19.OUTER CASING(for multi-cased walls OR LINER if a cable
Cummings Developments, Inc. FROM TO DIAMETER THICILVESS MATERIAL
+7 ft. S ft• g in. PVC
Company Name 16.INNER CASING OR TUBING(eotbarmal closed-loop)
2,Well Construction Permit#: FROM To I DiASiETEA I THICKNESS J MATERIAL
List all app&•able veil construction pervni6r(i.e.WC,County,State,Variance,e(c.) ft• n. in.
3.Well Use(check well use): ft. ft. tat
Water Supply Well: 17.SCREEN
Agticultulgl �MunicipaUPublic R. R FROM TO R. DIAMETER SLOT SIZE THICKNUS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) yl ft.
Industrial/Commercial QResidential Water•Supply(shared) ts.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt• 20 ft. PoriCemerd Pour
Monitoring Recovery et. ft.
Injection We
tr. tr.
Aquifer Recharge �Groundwatet'Remcdiation 19,SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology 13subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets it neeesas
FROM to D&SCRIPTION color,hardy soll/roeit slsaetu)
Geothermal(Heatin Coolin Return} r3Other(explain under#21 Remarks) 1 ft. tr
4.Date Wells)Completed: 1 Z r VWell lD# %
Ss.Well Location:
AmL dr�Ie.r2���EiTs_ tr. ft. omm-o ME)
Facility Ns Facility ID#(if applicable t R' it.
64 Joy ' ` olbo o ft. tL
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel identification No.(PIN) section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwoll field,one lau'long is sufficient) 22.Certific
�3V' a3, 13i N 90 oo -8501 w - ; !��; �z,-zl
6.Is(are)the well(s)oPermanent or Temporary -5rgreturc of Certified Well Contractor Date
By signing this form,I hereAv eerto that the well(r)Was(Were)wnstruded in accordance
7.Is this a repair to an existing well: [3Yes or ff)No vith 15A NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standwds and that a
Ifthis is a repair,fill oul knorm vcll construction information and explain the nature ofthe copy nfthis record has been provided to the well owner.
repair under#21 remarks section or on the back of7his fora.
23.Site diagram or additional well detafk:
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 1 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: �� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For inultiple hells list all depiks if different eeraniple-3 r@200'and 2 c@100'1 construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,information Processing Unit,
1ftvater 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 adth'ess 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.Huger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27094636
13a.Yield(gpm) 5 Method of test:Air Rotary 24c.For Water Sunuly&Infection 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: 2c7 Z completion of well constriction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016