GW1-2022-06263_Well Construction - GW1_20220628

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-:WELL CONSTRUCTION RECORD(GM14)
For hrternal Use Only:
1.Well Contractor Information!
Christopher Wachter 14.WATERZONEs
Well Contractor Name FROM TO DESCRIPTION
i-7 ft.
4448A t 40 6
ft. It.
NC Well Cantmctbr Certification Numbe!
T A IS;,OUTEItCASING(for iiiWti4iiid.WiRil. JL Tin fNER dikpfiiib%)�_
Cummings jDevelopmentsi Inc. FROM TO DIAMETER THICKNESS
MATERIAL
Company Name +1 ft. I 6 in. PVC
16ANNEW, SING
2.Well construction Perndt#- 0 2-2— 0 03-1 FROM TO I DIAMETER THICKNESS MATERL41,
List all applicable['well construction penubs i?.,UIC—Colmly,State,Variance,Vic.) ft. It. in.
3.Well Use(check well use):
ft. ft. in.
—ter Supply
Water Well:
IXSCREEN='
rMhAgdcultural E3Municipal/Public -PROM I To I DIAMETER I SLOTSIZE I THICKNESS I MATMAL
ft. ft. In.
Geothermal(Ijeating/Cooling So ; —
PPIA Residential Water Supply(single)
ludustrialtCommercial 13Residential Water Supply(shared) In.
Inigation 111p,434ROUT..
FROM TO MATERIAL
Non-water Supply Well: EMPLACEMENT METHOD&AmouNr
0 it. 20 fL Part Cement Pour
Monitoring !
i DRecovery ft. It.
Injection Well:i
Aquifer Rccha�ge ft. %
Groundwater Remediation
''M
M Injection
Aquifer
Aquifer Ste M-ge and Recovery Salinity Barrier
FROM TO
Agricultural
ft. I MATERIAL EMPLACEMENT METHOD
DStormwater Drainage ft.
Experimental
XPerimental Technology E3Subsidence Control ft.
Geothermal(Closed Loop) i
OTracer
G 01
Geothermal(H.eatmg/Cooling Retu.in) Mother(explain under#21 Remarks j FROM to DESCRIPTION(color,hanIness,soft/ruck type,grain sW.efea
5ft. SO i J
4.Date Well(s)Completed:U 7
Well M#
It
Sa.Well Location:
U, ''f
V-%— ft. ft.
Facility/dweer Name JUN- 9 s
Facility ID#(if applicable) ft.
—"T Ent) 5�>iMS"Dr. ft. (ink
Physical Address,Oily,and Zip I.
ft. ft.
'21i�REXARKS-.
918 E5 5'rl 1. t b
County 0 1 -
Parcel Identifleation No.(PM Jr
Sb-Latitude and!longitude in degrees/zninutes/seconds or decimal degrees: J
(ifwall field,one lainong is sufficient)36()C 1 22.Certific n;
Le
N _21 0 2 Q -2 W
z _Z7
6.Is(are)the wen OPermanent or 13Temporary Ignatu ortiGdWcll Contract
or Data
this
signing this form,I herebv cenlry that the ivell(s)ivas(were)constructed in accordance
.V'Jg g
7.Is this a repair`to an existing well.* 13yes or fflNo with 15ANCACO2C.0100o*rl5A]VCACO2C.0200 Well Construction Randal ds and that a
If Is a repair fl#old known well-onst'7611on btronnallan and explabi the nature afthe copy of this record has been provided to the well owner.
repair under#21 relParks section or on the!back ofthisform.
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'l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled-
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /249
-3@200'aud2@100)
For MU11010 Wells hst all depths tralifferenti,(krample ON 24a. For All Wells Submit this form within 30 days of completion of well
f construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is aboye casing,use,*+,, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diailheter: 6
24b.For Infection Wells-. In addition to sending the form to the address in 242
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,ca,61e,direct push,etc.) I construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: -
1636 Muff Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm);[ Method of test: Alr Rotary 24c.For Water SuRply&Injection Wells- In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:. /2-0-z completion of well construction to the county health department of the county
i where constructed.
Form OW-1 North Carolina Depariment ofEnvironnicnial Quality-Division of Water Resources Revised 2-22-2016