GW1-2022-06266_Well Construction - GW1_20220628

For
TWELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
1.well Contractor Inforination-
Chiistophor Wachter 14..WATERZONES. ._rz;
Well Contractor Name FROM I TO DESCRIPTION
4448A
ft. fr. 2 1,11' 3
ft. ft. I(ci a7
NC Welt Contract6 Cortifleation Number
Cummings'l,Developments; Inc. FROM I TO I DIAMETER
ft.
Company Name +1 6 PVC THICKNESs MATERIAL
16ANNERVASING 011-
2.Well Construction Permit#: FROM I TO — I DIAMETER I THICKNESS I MATERIAL
List all appllcabl,,�!lveli"GJ7strUcliolipennits Ji.e.MC,County,State,Variance,ele.) % ft. in.
3.Well Use(check well use): ft. ft. in.
ter Supply Well: 17.SCRME
FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
Agricultural [3Municipal/Public
ft. ft. In.
Geothermal(Heating/cooling Supply) I
pply) Residential Water Supply(single) —ft. ft. In.
lndusWal/Con6ercial Residential Water Supply(shared)
unteation
FROM To MATERIAL ENFL-A-MIMT METHOD&-AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Part Cement Pour
:lMonitoring DRecovery ft.
Injection Well:
Aquifer Recha�go 1343roundwaterRemediation ft.
J9.'SAN RAVEL�P,,kCK�',(ffiiiniiii�abli)--
Aquifer Storage and Recovery E3SaIinityBmTier
FROM TO - MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3StOrmwater Drainage ft. ft.
Experimental Technology 13subsidence Control ft.
Geothermal(C iosed Loop) OTracer
20;DIRMJILL iLGG
Geothermal oling Retuin) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.Jhnrd.e$%solUrock t"g.gMn sW.gtr_)
ft.ft.
water
4.Date Well(s)ibompleted:U9-27'ZZ- WeIlID# 5/S'f` 2- ft'
i
5n.Well Location: ft. ft.
ft. ft.
F7acilit�dOwnerNmite _FaCII-IrID#(if3ppIicablc) -f t. ft.
C2 A a 2WJ R. ft
!_;Nn Pr­F7v -i-ci I
Physical Addess, and Zip Rft. M-1Q16O
A nt
County Parcall Identification No.(PIN)
5b.Latitude and:longitude in degrees/minutes/secondsI or decimal degrees:
(ifwall field,one laillong is sufficient) 22.Ce ation,
Ito
.0 11a I/- it, "77 z _N 31. 1 yl
6.1s(are)the well(s) Permanent': or 13Temporary Signalt
ad Well Contractor Date
v sig,71119 this form,I he"eAV cerfirY that the ivell(s)teas(were)constructed In accordance
7.Is this a repair to an existing well'. 13Yes or MNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards mid that a
#"thls Is a repair,fill out known well consin'iction leonnallon and explain the nature of the copy of this record has been pravided to the well owner.
repair under#21 remarks section or on theiback Of this fonn.
23.Site diagram or additional well details:
8.For Geoprobd])PT 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,Olily I OW-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: 42 //o XW 249. For All Wells Submit this form within 30 da s of completion of well
For multiple ivelk list all depths J(4Verentj(kraniple-3@200'and 2@1001 y
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ifivater level is aboy'R casing,use
1617 Mail 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)L Method of test- Air Rotary 24c.For Water Supply&InIgetilon Wells: In addition to sending the form to
13b.Disinfection type: HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnvironmantal Quality-Division ofWnter Resources Revised 2-222016