GW1-2022-06213_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER=ZONES
Well Contractor lame FROM TO DESCRIPTION
4448/4 �}
ft. ft. � Z y 0
ft. ft
NC Well Contractor Certification Number
I&OUTER'.CASINGWO multi=sused;wells OR L'1NER'lies"'lketile
Cummings Developments; Inc. FROM I TO DIAMETER I THICKNESS MATERIAL
Company Name i +1 ft. j f ff. 6 In.
PVC
I 16.INNER CASING,ORTUBING(e otlieemal clo§ed=rills
2.Well Construction Permit#: FROM TO DIAMETER I TMCRVFSS IMATERIAL
List all applirahlej'well ronstruction permits(i.e WC.County,Slate,variance,etc.) ft. n. in
3.Well Use(check well use): ft. it. In.
Water Supply Well: ; 17:SCREEN
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL ~
' [3Municipal/Public ft. ft. in.
ply) oResidential Water Supply(single) fr ft. in
hldustnaUCOmmerC al g p 13Residential Water Supply(shared) _
Geothermal Heatin Coolin Su
Is3i 2ROtTi;:... �.
Im shot FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No,
Supply Well: 0 ft. 20 It. Port Cement Pour
Monitoring ! Recovery ft. ft.
Injection Well:f
Aquifer Recharge ®Groundwater Remediation . ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19::S#ND/GRAF/ELEAEK;if!a`lie aBie = a _
FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20:DML iI1NG;LOG:attach4-fddlNonelsheeteaf:neceseae z
Geothermal(H i eatinglCooling Return) rlOther(explain under#21 Remarks) . FROM TO DESCRIPTION(cater,hardness,routrack�f a graln stye.etc.)
0 ft. /� ft.
4.Date Weil(s)Completed: ~��Well M#
Sa.Well Location: rt. ft.
ft. ft. J%n. .M.7 4,.5 9( i,:,4.f
Facility/Owner Narita Facility ID#(ff applicable) ft• ft.
N►cKs did �� h�tl.c a7 o a ft. ft.
Physical Address,aily,and Zip ! ft. ft. rocT ,•,:?; Urai
rat�i e g 9 =a a 9 o a�
County T Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laoong is sufficient)
/ r 22.Certifica
�� oar 3�� N 79°/y.3 W
6.Is(are)the weYl(s)MPermanent i or 13Temporary Signe Certified Well Contractor Date
By signing this fw�n,I heiehv cerl(fy that the well(s)was(were)coasructed In accordance
7.Is this a repair to an existing well: 13Yes or INNo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Consbnrction Randtu ds mud that a
Phis is a repair•fill out known well construction Inforaallon and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 rentarkssection or on thR back ofthis form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW 1 is needed.1Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.
24a. Far All Wells: Submit this form within 30 days of completion of well
For ntultlple wells 11c1 al!depths lfd(B'erentl terample-3@2000 and 2@100� construction to the following:
10.Static luster level below top of casing:_ J (ft.) Division of Water Resources,Information Processing Ywater level is above casing,Rise g Unl t,
1617 MailService Center,Raleigh,NC 27699-1617
11.Borehole dialpeter: 6 (in.) 24b.For Infection Wells: In addition to sending the foam 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.) I construction to the following:
I Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS O11 1636 Mail Service Center,Raleigh,NC 276994636
13m.Yield(gpm)i Method of test.Air Rotary 24c.For Water Supply Bc 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,Dlsinfectionitype: HTH Amount: 2/60 Z completion of well construction to!the county health department of the county
where constructed.
Form GW-1 North Carolina paparimcnt ofEnvironntontal Quality-Division of Water Resources Revised 2-22 2016