GW1-2022-09989_Well Construction - GW1_20221104

' WELL CONSTRUCTION RECORD GW-1 Print Porn
For Intemel Use Only:
I.Well Contractor Information:
Christopher Wachter
Wall Contractor Name 14.WATRRZONRg
mom TO ON
4448A
NC Wa11 Cmarecou Cmdgntion Number ft. &
Cummings Developments, Inc, IS.OUTER CASING for mull maedweta ORLINRR Ua his
FROM TO DIAMETER TNII11911
NER 6 eable) .AL
Company Name toN •1 h I ft. 6 in
//'' q PVC
2.Well Construction Permit#:�r�- Q� U66 In pI` 16.INNER CASING OR TUBING aotharmalelwed-Im
Lisr rt!l upphral,le rvell ronnrurlim,pe ndn P.C.UK,County$n R.Yorlunre,Kr o ry WROM r` TO
3.Well Use(check well use): DfAMaTBB THICKNESS MATERIAL Water Supply Well: R fL le.
AgricuI?.SCREEN
Geotheltwal OMunicipal/Public FROM To DIANa1Tm SLOT BIz6 THICKNESS MATERIAL
Geothermal(Heatlng/Cooling Supply) B• n. In.
®Residential Water Supply(single)
InduatriaVCommerciel OReaidental Water Supply(shared) R' R. le,
Irri tion m.GROUT
Non-Water Supply Well: FROM ASATanrA1. EMPLACratEx•T mrerxGo ,sarouxT
Monitoring0 R• 20 IL Recovery PanCan,eua Pour
Injection Well: fL @
Aquifer Recharge OGroindweter Rcmodiation N' R
Aquifer Storage and Recovery OSalinity Berner 19'SAND/GRAVEL PACK
a
Aquifer Test OSmm FROM A rwater Drainage R. 8 MA7EBIALXMIPLACRXENTMETHoD
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OT,acer R. O.
GeOtliellllal Heatin CoOGn Retum) FROM LOG . malnooTIONlrole
Other(ex lain under f121 Remarks FROM TO DRACRIfrfloNleolar naraa,...rauroaa
4.Date Wells Co R• !L <— ale,au.
mpleted; - I Z - Z Z well ID#
R. zO R
Fal!lmlh��y/OwrcrNamo e 6
Ov.J�10 F. Hay ID#(if�hia) tr• R A
�Q�54v� "�� ehcLrYD m w
P/fhfl1Rio.l Adi((y''m�au,City,Soft Zip R. - t Brut
Lu l R.'1`F� 31. tL
Colmty Parcel idontiteation Uo.(PIN)
Sit.Latitude sad longitude in degrees/minotes/seemmis or decimal degrees:
(if well field,one he/long is auaicicnt)
22.Certlghm
�G2 .ok� N ')I43 . 18s
w
6.fa(s ra)thew ell(e
)Permanent or OTemporary Signaturo tad We mummer Detc
7.Is this a repair to an existing well: Yes or By rlgning thb form,.I helrAv arrtyy Thal tit wrlf(s) ,m(were)coxs0•xrted or accmda¢e
Ifthb Is a rrPae:fie our kee wm wcli em oll"daOxformaflon n®eap sin the nutura of the coYY xl rh��emrdh AC beer Pmv or ded�o�e x ll ol�Well Cmnlrucrlan SYondards and that a
repair under#21 m4arkrsrctim,m on the backoJ'Ihbfmvx.
8.For Geo robe/DPT or Qosed- 23.Site diagram or additional well details;
P Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constmon,etl only 1 GW-1 is Heeded. Indicate TOTAL NUMBER of wells
construction details. You Huey also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 1.2 SUBMITTAL INSTRUCTIONS
(�)
Formulliple crib/fatal/depths ildl$nrmr Gxam01-39200'mtd2®1001) 24a. For All WeBa: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing; ) Division of Water Resources,Information Processing Unit,
K,uatrr level/a uiwve ca<ing,use°+'• fit.
1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (inJ
24b.For Injection 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 pull,etc.) construction to tie following:
FOR WATER BUPPLY WELLS ONLV: Division of Water Resources,Underground Injection Control Program,
1636 MAB Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Z Method of test: Air Rotary 24c.Far water Supply& I I x r.
16�ylLIn addition to aendutg the form to
13b.Disinfection type: HTH �LO' 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.
Foin GW-1 North Calellm Department of Euvironn,cnml Quality-Division of water Rmourax
Rcvhed 2-22.2016