GW1-2022-07605_Well Construction - GW1_20220817

P, iht Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WACHTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A
tt. tt. DESo , 110
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a e
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER lieabl
THICKNESS MATERIAL
+1 ft. ft. 6 5/8 1O' .188 G.STEEL
Company Name
i q 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: L 4,a� 1 �E L N 20 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public [L ft. in:
Geothermal(Heating/Cooling Supply) Ritesidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. O ft. PORT.CEMENT POUR
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GAVEL PACK if applicable)
Aquifer Storage and Recovery Salinit}Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. tt. J
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [l Other(explain under#21 Remarks) FROM ft To ft. DESCRIPTION color,hardness,soil/rocke, rain size,etc.
01
4.Date Well(s)Completed: Well ID#
ft. ft.
2 rt. ft. t
Sa.\Well
�Location: ft.
`
cam} F 1 hYU 11 O�Y'� ff �L V ft. AG. .�.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
as-1£� aclC do le C� Ift ��as3 ft. tt. AUG j 7 2022
Physical Address,City,and Zip ft. Ct.
�kCKJ 9- 49-1 I&(7 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 22.Certifi on:
3`y 00 -(j�D N 79O ZS, S37 W / -�-ZZ
6.Is(are)the well(s)oPermanent or OTemporary Sigma Cc;PeTWclI Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis.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. 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: /�O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000'and 2@100') construction t0 the following:
L I 10.Static water level below top of casing: an (ft.) Division of Water Resources,Information Processing Unit,
If 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
ROTARY above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /O Method of test: AIR ROTARY 24c.For Water Supply&Infection 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 type: HTH Amount: Z completion of well construction ti the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016