GW1-2022-10000_Well Construction - GW1_20221104

• ' WELL CONSTRUCTION RECORD GW-1 Print Porn
For)eternal Use OD y:
I.Well Contractor Information:
Christopher Wachter
Well Contractor Neme 14.WATERZONBB
OM TO DfatCalFt'ION
4448A FR R. A. � t
04
NC Well Com.,,rConifleation Nambar ft. It.
Cummings Developments, Inc. 1S,OUTER CASING formulH-celled venal OR LINER tin hie
FROM TO DIAMETER TNICICVE9a MATERIAL Company Nome +1 R, 2 R•
s in. WC
2.Well Construction perttdt#• 16.INNER CASING OR TUBING( eothermal eloteddoo
List all t PIIOM TO DIAMETER
apple(Check
+ck w nrtrseion pr da Rt.UIL,County.Stall.V.1.ce,I'll R TmC1LVESa MATERIAL
3.Well Use(check wen use); 6 m.
Water Supply Well: Jr. R in.
Agricultural t7.BCRERFAgriculturalOMunicipaVPublic FROM TO DrAMa1aR aLOT a12E TNICKREsB MATERIAL Geothermal(Heating/Coo' supply) R• R. hL
®Reaidcntial Water Supply(single)
Industrial/Commercial OReaidential Water Supply(shared)
Irri ation PP Y( areL.GROUT
Non-Water Supply Well: M TO suTaaw, astrLAceMervr METHOD AMouNr
Monitoring R 0 ft. 20 IL pyt cannott Parr
Injection ell; Recovery ft. h
Aquifer Recharge OGroundwatcr Rcmcdiation ft. AL
Aquifer Storage and Recovery Oselinity Barrier 19.BAND/G12AVEL PACK a kable
Aquifer Test FROM TO MATERIAL PLAC¢MPM METHOD
OStomlwata Drainage EM
rt. ft
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OT�acer n' R.
Oeothermal(Heatin Conlin Retum 20•DRILLINGli attach H
Other(explain under#21 Remarks FROM TO D 6.mmm...,oivrw, raterw.erq)
4.Date Wells)Completed: 15 Z Z R. 3 IL D >
WeB ID# R. a,12p m
Sea.Well Location: R it
PsFSky/OwrorNsme E L.. —r r .__
ParmO'1D/(ifopplieeble) R. R.
11.E X City, oa bra m A hut,a42,� ti IL �
Phlukal Adtrew,Clly,and Zip �''—�'s�lL
County, (118 0()q 21.REMARKS -
I'me]Idontif"i No.(PIN)
3b.Latitude and longitude In degreea(mintReaheconds or decimal(if well field,rum laWong is sufficient) d of
32.Cerinks
ILI
w _Z z
6.Ic(are)the well(s)IOpermancnt or —1S
�Temporery S taro oR Commoner D�
7.Is this a repair to an existing well: YH or nbrE Ws form.1 grrebv car((y tlwl(he well(,d war(were)cmuburfeQ ID ummdaern
ifthis is a n pa/n pl oat known wel(cwma'ra•Nop hreallon a d plain the naarra o Ile, ropy"AANC'C 0 ho 0100 pravidrtl M N 0a 11 o2t00 Wel!Cmulrunlan SVaodmds and Thar a
repair under#21 ren erkr section or on the back of1his form.
23.Site diagram or additional well details:
S.For Geoprobe.IDPT 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
��
9,Total well depth below land surface: SUBMITTAL INCT'RUCTIONS
(R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwh/p(e nulls lht all dep/As if6ffereni lrxonrpla 3®200'mW2Q/OOy
construction to the following:
lf+wter lnveik use^t.,
10.Static water level below[op of casing: 3 ) Division of Water Resources,Information Processing Unit,
uAow raaixs (fL
1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 6 0%)
24b.For Injection Wells: Tit addition to sending the form to the address in 12,Well construction method: Rotary above,also submit One copy of this form within24a
30 days of completion of well(i.e.auger,rotary,cable,direct push,time. construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Rotary 24c.For Water Supply e. r-+__.,_
R W.}Jls- 1n addition to aevding the tbtm to
13b.Disinfection e: HTH the address(es) above, also submit one copy of this form within 30 days of
UP Amount: `Y r C completion of well construction to We county health department of the county
whore constructed.
Foin GW-1 Nonl+Cnmlim Departimm of Environmental Quality-Division at'Wmcr Raourcca
RNked 2.2E-20I6