GW1-2022-06270_Well Construction - GW1_20220628

WELL C®NSTRUCTION RECORD(GW-Y) For Internal Use Only:
1.Well Contractor Information:
Christopher Wachter 14.WATER-ZONES _
Well Contractor lame FROM TO DESCRIPTION
4448A ft. iL 017S
1'
NC Well Contractor Certificationft. & _oa Numb /72
ci•
18:,OUTER CASING(for m"01-4ased wetly:OR1INER'if-e `II--b'le
Cummings Developments!, Inc. FROM TO DIAMETER THICKNESS MATERUL
Company Name +1 fL623 ft. 6 in. PVC
t;r+q� ,� T O Q, 16:INNER CASING OR-.-TUBING.('eothermaUcl'osed=trio
2.Well Construction Permit#:_ib�1�J1 0()� FROM To DIAMETER THICKNESS MATERIAL
Lint all uppllrahleiweil ranstruchon pernnts r.r.UIG;Coano} Slate•Var lunce,ele.) ft. It. in.
3.Well Use(check well use): it,
Wa ter Supply W�= IZ`SCREEN _
Agricultural FROM TO DIAMETER SLOTSIZE` I THICKNESS TMATERIAL ~�
0Municipal/Public ft.
Geothermal($eatinglCooling Supply) Residential Water Supply(single)
Industrial/COlnmerCiel ft. ft. in.
Residential Water Supply(shared) 18:.GROUT
irrl orlon FROM TO MATERIAL r A EMPLACEMENT anmrrHOD&AMOUNT
Non-Water Sapply Well: 0 ft. Pe ft.
Monitoring ' Port Cement Pour
Recovery fL ft.
Injection Well:
Aquifer Recharge13Groundwater Remodiation ft. ft,
Aquifer Storage and Recovery [3Salinity Barrier 19:SAND/GRAVEL iPACK{
FRUM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Storniwater Drainage ft.
fL
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop.) OTracer 2Q.DRILY:ING L OG:alfaeti addttloaiel sheets lfinecessas"`. "'
�.;.
Geothermal(Heatin Cooling Retuin) Other(explain under#21 Remarks FROM To DESCRIPTION fart r hardness solarock e n size,era►
ft. Z ft. v
� i
4.Date Wens)Completed: Well M# 2,ft. 0 ft.
Lk
Sa.Well Location:
� c if. ft. `i,�1,,.-Y,..•�3-.,-.
Facility/O a ante Facility ID#(ifopplicablc) ft. ft.
ft. f6
P ical Address,City,and Zip ft. ft. Ir+"Oi'e'li b«n : r acW-•T-..Tt� O
'00 rig+
2 ga qq 3 4a l 1 _ 21 REMARKS
County01Parcel Identification No.(PIN)
I
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lainong is sufficient) 00�-
22.Certitic on:
�7
6.Is(are)the well(S)JMPermanent; or Temporary ignaturo citified Well Contractor Date
signing this fan4 1 herelty cert(/y that the wells)was(were)constructed hi accordance
7.is this a repair to an existing wellI ®Yes or �Na Wth 1SA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
iflhis is a repair•fill oul known well construction lrfornmlion and erplain the nature oflhe copy rfdris record has been provided to the well awuer.
repair under#21 remarks section or an Ihe!back of this form.
23.Site diagram or additional well details:
8.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 1 GW-1 is needed.j Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (it•) 24a. For All Wells: Submit this form within 30 days of completion of well
For loahiple wrlls iistall depths lidi�'erent!(exarnpie-3 200 and 2©100�
construction to the following.
10.Static water level below top of casing: -�i (ft.) Division of Water Resources,Information Processing Unit,
l/ivater 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:
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)I 20 Method of test: Air Rotary 24c.For Water Sunuly&Iniection 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-1 Nardi Carolina Department offinvironmcntal Quality-Division of Water Resources Revised 2-22-2016