GW1-2022-09969_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
CHRISTOPHR WACHTER 14 WATER ZONES
Well Contractor Name PROM 1 TO DESCRIPTION
ft.
4448A it.
n. n.
NC Well Constrictor Certification Certification Number
15.OUTER CASING for saW-used webs OR LINER fita 'nble
CUMMINGS DEVELOPMENTS, INC. PROM I TO DIAMETER rmcKNEss MATERIAL
N ft. ft. E in. PVC
Company Name
"r 09 I6INNER CASING OR TUBING eolbeE92 elmed-ba
2.WeB Camstructlon Permit#: W r•.Z �ODVV rRON TO DIAMETER Tf11CKVEJS MATERIAL
List all applicab/P well ronnraction permits C..e.UIC.Co.,,,Sala Variance,
3.Well Use(check well use):
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOI'SIZE THICKNESC MATPRIAL
Agricultural OMunicipal/Public
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) tr ft im
Industrial/Commercial Residential Water Supply(shared) It GROUT
71irrigation FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Noo-Water Supply Well: C7 ft. ft. PORTCEMENT POUR
Monitoring Recovery RL ft.Injection WeB:
fl. R
Aquifer Recharge (3Groundsvater Remcdiation
L PACK U
Aquifer Storage and Recovery OSalinity Barrier It.SAND/GRAVE alicable)PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage rE 1
Experimental Technology OSubsidence Control fl. fl.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG stlscb additional sheets if meeesu
Geothermal Heatin Conlin Remm) Other(explain under#21 Remarks) Most To DFCCRIM ION I.omr h.mn.s —iv.rk ram rim..m.l
I4. b fl. // fL df/
Date Well(s)Completed: 4—�2- Wa llm �( it. R/ R h /P•
5a. ell Location: _j n• Y�0 ft.
Al" R R
Faci blc)it/Owner Ne/ ��JA Facility lD#Hfapplica fl. fl.
R2d V/t�K.1 • lau�w� ft. n.
Physical Address,City.Ad Zip �P �/oe rt. ft.
Drµft 9D So77s�7r 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavloag o su'ciend f 22 fl oDr
350 SO. y 3(0 N oR a�� W 9-G-zz
6.ls(are)the weli(s)OPermanent or OTemperary Signature ofCcrtified Well Contractor Date
By signing this Joint./hereby cenh that the wells)was/were)ran imcted in acrordance
7.Is this a repair to an existing well: OYes or ONo with ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
lfthis u a repair.fill our known well construction hint malion and rsp/ain the mature ofthe copy ofthis record has hers provided to the wrll 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:
y�o
9.Total well depth below land surfs": IR.1 SUBMITTAL INSTRUCTIONS24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wellslist all depths fdifferrN leramplP-3Q100'and 2Ql00') construction to the following:
lo.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wmer level is shore casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 248
12.Well construction method:
ROTARY above, also submit one copy of this form within 30 days of completion of well
construction to the following;
(i e.auger,awry,cable,direct push,etc.) g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13s.Yield(gpm)1 Method of test: AIR ROTARY 24c.For Water Supply &Infection Wells: In addition m sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: �70Z• completion of well construction to the county health department of the county
where canstmeted.
Form GW-1 North Carolina Department of Envimnmcntal Quality-Division of WateT Resources Revised 2-22-2016