GW1-2022-06269_Well Construction - GW1_20220628

WELL C®liT�TRUCTH®N RECORD W g £.. ;1?r fit Fore
For hrternal Use Only -
I.WeII Contractor Information:
Christopher Wachter
la..WATER
Wc11 ConuactorNemo zoNE3 ,- -• . .-.: r�:_.. .. �::. .:
4448A
FROM TO DECCRIPI'!ON
�' ft. 13�
NC Well Contractor CafiBeation Number ft. ft.
Cummings Developments; Inc. IS.aUTER CUING fonmiilH=rased.weDt VON
LIN>C ier
FROM TO DIAMETER THICKNE86 I MA7ERIALy
Company Name
PVC
�.Well Construction Permit#: I J as htlh/.! �naM ER CASINGORTMING "eottieimnl:etosedaoo
Ztstall appprableiwe//eonsMrctTonpermt�srye.UIC,County,Sfafe,Va�faace,err.) ft. TO DIAMETER
THICILNE89 MATERIAL
3,Well Use(check well use): ft. Im
R• ft. in.
Water Supply Well: 17.SCREENAgriaultutal FROM TO }
13Municipal/Public DrAME6ER Br.OTBIZE THICKNESS MATERIAL
Geothermal(Heating/Ccoling Supply) JEResidential Water Su 1 (single) ft. n. !d
htdustrisycommercial pp y( g R• ft. in.
®Residential Water Supply(shared)
lAquifer
tion `18.wWat®r SDpply Well: oM ToMATLnLU. EMPwcEMErrrMerxon AMounrrM0 R. 20 fL Port Cement Poueft.
quiferRcchargo ®GroundwatcrRcmediation ft. ftquifer Storage and Recovery [3Salinity Barrier I9.SAND/G Test FROM ToMETHOD
�Stormwater Drainage ft. %xperimental Technology �Subsldence Conhol
eothermal(Closed Loop)eothermmal Heatin Coolin Returlr 2LAMRIL1:lNG.LOG.atff ach`iiddlHonarebeetq(f nece cw"
Other(explain under#21 Remarks To D6RCnIP7Y0N tmtar saturacl,
ft.
4.Date WIN Completed: (40'3:Z�' Wall W# Z ft. /
52..Wen Location*, I tr. !fi
ft. ff. Rom `
FacilttY/ �
OwnerNatno Fact iityl1#afapplicable) ft. ft.
111„ atyr r - �d I a8 r 6rbve- fa 1L
Physical Address,pity,and Ztp ft.
L.�l�0. ft' lnic,F3,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one l000ng is suflicicnt)
-3-6 e Z o- u Gl 22.Ce ea
6.Ys(ore)the weHOIDPermanent or Temporary ignsturo of Certified Well Contractor
Date
7.Is this a repair to an existing well. !pp��Yes orp�,No BY s/gning this jori,!fieirhy cerl(fy thal the tvell(s)was(were)cortstruped hi accordance
MONS/s a repaht fA(oal known tvrll oonsuuetion t oranalan and xpiata the nanae ajthe COPY ofthwith ISA is Meard h#been pro100 or w tied to die well a ve Well Cautrerctton Standards rued llral a
repair under#21 reinarkeseulan or on tho'backoflldsjatrn.
r.
23.Site diagram or additional well details:
c Tor construction.
obelDPT or Ciossd-Loop Geothermal Wells}raving 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:
9.Total well depth below land surface: SUBMITTAL INSTRUCTYONS
POP ntuNlple Welk lfl all depths{/deraat(rxmnpk0-3@200'and2®100') (ff) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1AVXerlevel ivaboveeashtg;ttre +'�
I I.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699.1617
24b-For In ectio t We)1s: 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.o•autp:.rotary,anble,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources;Underground Injection Central Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: Air Rotary 24c.Far WaterYnteetlon Wells: 7n 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:/70 Z completion of well construction to the county health department of the cottnty
where constructed.
Form GW-1 No°h Carolina Department ofEnvironntontal Quality-DivisIon of Wator Resource
Revised 2r22 2016