GW1-2022-06268_Well Construction - GW1_20220628

WELL CRNSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contra4or Information!
Christopher Wachter 14-WATERZONES
I-
Well Contractor Name FROM TO DEsciupTiON
i ft. it
4448A
NC W01 Contractor Certification Numb ft. ft
11DUTIERCAS ift2-VaMI..",
Cummings IDevelopments', Inc. mom i TOING(fdi!HDIAMETER eUs��PTRIi—IIC-K-N-E-SLS MATERIAL
Company Name +1 ft, 1-22 ft. 8 In. PVC
16.INNEW ING ORTLUBING.'(P'dotiferm2l:acsid466bf,-.
2.Well Construction Permit#: L321 - 00 LOB FROM TO I DIAMETER I THIMESS I MATERIAL
Lloallappli,able U C.County,Slut,,V
z arlunce,air.) ft, ft. in.
3.Well Use(chick Well use): ft. ft. In.
I
Water Supply Well: i IVSCREEN:�"
Agdcultuml FROM I TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
a
A 13MUnicipal/Publir
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
li� ft. ft. in.
IndustrialiCommercial
Residential Water Supply(shared)
Irrigation
FROM TO MATERIAL
— EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 ft- 20 ft.
PartCement Pour
Monitoring Recovery ft. - ft.
M Injection -
Well:
nAquifer ltecharge it.I ®Groundwater Remodiation
Aquifer Sto M'ie and Recovery -l .'SANI'IGRAVEL-'.,PACK,-Iff4'2orjni�.sTifel�-r
Malinity Barrier
Aquifer Test ; FROM To — MATERNAL EMPLACEMENT METHOD
13stom1water Drainage ft. ft.
Experimental Technology 13Subsidenee Control
ft.
Geothermal(Closed Loop) 13Tracer --20.*DRILLINGXQG1g4tta I
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soll/rack tyye n size.etc.)
4.Date Well(s)Completed: Z-Z Well ID#
- 7 ft• X-ld ft-
52.Well Location: ft. ft
ft. ft.
—5 � IFF[7
Facility/Owner Nerho Facility ID#(if applicable)
.?la9 1 0 R. ft. 2 8 2022�e- r-1f,,re-r 81,, —
Physical Address,City,and Zip ft. ft.
L Pr rV M-c�59 Unii
-CO. e-'!
'2
County
Parcal Identification No.(PIN)
5b.Latitude and longitude in degreis/minutes/seconds or decimal degrees:
(if wall field,one*0119 is sifficient) 22.Certific or,1:
If N ° I y v w �%�` y-Z�-z�
6-Is(are)the wgII(SoPerniancnt or 13Temporary siggnatarc eFtified Well Contractor Date
signing tits form,I hereAv cerilry that the wells)was(were)constructed hi accordance
7.Is this-a pail to an existing well, 13Yes or JKNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards mid that a
V'Ihis Is a il'Z"-fillclllknuwn lycliconstAtellon l4rannation and explain the nattwe ofilse copy of this record has been provided to the well osviten
repair under#21 rej'uarkssecilou or on 11101ba ckofthisfo",1.
23.Site diagram or additional well details:
8.For Geoprobe/DFr or Closed-Lo'0p 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. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled- I I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfice: 24s. For All Wells Submit this form within 30 days of completion of well
t all depths For multiple%wils i4t —0t.) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
it water 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 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 Program,
FOR WATER SUPPLY WELLS ONLY: ion Cont
i 11636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)1 Method of test.- Air Rotary 24c.For Water BMW&Inleeflon 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 itype: HTH Amount:. J a completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparlmont of Environmental Quality-Division of Water Resources Revised 2-22-2016