GW1-2022-07906_Well Construction - GW1_20220823

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WELD CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informations
Chiistophor Wachter 14.WATER•ZONES .
Well Contractor Nome FROM TO DESCRIPTION
4"8A ft. ft. ip 9
it. ft.
NC Well Contractor Codification Number
15.OUTER;CASING for multi'casedmills:OR<L'iNERv lice mbte E _
Cummings Developments; Inc. mom TO DIAMETER THICKNESS MATERIAL
Company Name *t fL f4 a hr. PVC
�� ("7 16:1NNER CASING OR.TUBING(eotGerrtwfiel&iW4 a
2.Well Construction Permit M w i 1 — o 0 1 5? a FROM TO DIAMETER THICKNESS I MATERIAL 4~
List all applicable jive!!construction pennus r e.UIC.County,State.Varhmce,etc.) H. R. in.
3.Well Use(check well use): ft. it. hL
Water SuPPIy,Well: 17.SCREEN i _-
Agl9CUIlU191 FROM TO DiAME'I%R SLOTSIZE THICKNESS MATERIAL^�
13Municipal/Public R. R. I in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single)
ft. ft. to
lndustrieUCortimercial 13Residential Water Supply(shared) _
Irri lion A&.0ROUT.-_
-' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT~
Non-Water Supply Well; 0 ft. pp n• Port CemaM Pour
Monitoring Port
ft. ILInfection Well:
Aquifer Reehargo [3Groundwater Remediation f %
Aquifer Storage and Recovery [39alinity Barrier _19.:SAND/GRAVEL;PACK;
FROM TO MATERIAL J EMPLACEMENT METHOD
Aquifer Test �Stosmwater Drainage tt• ft.
Experimental Technology 13Subsidence Control R. tt.
Geothermal(Closed Loop) E)Tracer 2WDRILLING:LOG:detach additional shce`tss;fUdeoWsai,
Geothermal Heatin Coolin Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION loolor.hordnem sofuroek 6 rain slag•eta
f�.�r 19 -Z Z
4.Date Wells)Completed: Well EN/ 2� ft.
Sa.Well Location: L4 Lj ft.
n� / 0V
m
Facility/Owner Name Facility ID#(if applicable) tt• & "--
_I�( r 1 4 QLnA 71 C1 Chat')P /-A'/ AUG-2 2022
Physical Address,City,and Zip-) It. ft.
1� 9 a �►g S 21 REIVIARK6 :, p-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or deelmal degrees:
(if well field,one b0ong is sufficient) 22.Certifies
°10�003' N .79601,113�
W 7/9- Zz
6-Ware)the well(s)iMPermanent, or Temporary of Certified Well Contredfor Date
By signing this torn,,1 herebv cerl(/y that the wells)was(were)constructed In accordance
7.Is this a rep*to an eidsting well: [3Yes or JMNo with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jil!out known well construction lrfonuallon and explain the nature of the copy of this record has been provided to the well corner.
repair under#21 remarks section or on the back oflhisfonit.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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,only 1 GW-1 is needed.jindicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled-
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (1t•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nr/is list all depths(l d(�erentj(exanp e- 100'aid 2®100� 3's P
construction to the following:
10.Static`water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if avatvr!eve!is above casing use +` 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (in.) 24b.For Inleetion 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 Igjection Control Program,
2 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)i ..7 Method of test: Air Rotary 24e.For Water Sunniv&Inleetion Wells: In addition to sending the form to
HTH Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �u completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Rcvlscd 2-22 2016