GW1-2022-10085_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD(GW 11 Print Form
For Internal Use Only: .
1.Well Contractor Information:
CHRISTOPHER WACHTER
14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
4448A B. ) R.
NC Well Consactur Certification Numbcr B• R
IS.OUTER CASING for multi<aud wel OR LINER its kable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNEM MATERIAL
Company Name *1 R R 6518 in. 188
G.STEEL
2.Well Construction Permit#: 1-I 1 7 Z W EL.N Z Z 16•INNER CASING OR TUBING rothermai closed4oppi
1p DIAMETER THICKNESS
MATERW,Lvr all applicable we(/construction permits Re.U/C Coanry,Sbb. Fariance,arc.) PROM R R In.
3.Well Use(check well use): R. R. iw
Water Supply Wen: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT 817E TmCKlung MATERIAL
[]MunicipaVPublic R h. la.
Geothermal(Heating/Cotling Supply) Residential Water Supply(single)
IndustrieVCommerciel R• R. lu
[]Residential Water Supply(shared) ]g.GROUT
fl- mite PROM TO MATERIAL EMPI.ACF.MENTMETHOELAMOUNr
Im
NoR-Water Supply Well:
Monitoring Recov D R R PORT.CEMENT POUR
e4' fL fl.
Injection Well:
Aquifer Recharge Groundwater Remediation R R.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK tl
FROM TO MATERIAL EMPWCEMENT METROD
Aquifer Test []Smrtnwater Drainage R R
Experimental Technology []Subsidence Control R ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional eherb Kne
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) momTo R DESCRIPTION eobr"romm."urorh q m. arc.
ft. ;
4.Date Well(s)Completed: I D-15 Z Z Well III# R. 1.�y,.., R
Sa.Well Location: R. �V R. r
ML LO;I b1A r.-i R R a
Facilty/Owner Name Facility ID#(if applicable) nu nA. )ngi
gas�6r 10—
Physical Address,City,and Zip R ft. rywaIDOG
1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient)
) I 22.CertiBcallon•
3� O all. y zs N 72R AT ITI W
10 vs-U
6.Is(are)the watt(e) 7�Permanent or ®Temporary Signs ofCanifie IContractor Dab
signin form,I hereby entity that the well(s)was(were co vc) unted In accordance
T.Ill this a repair to an existing well: []Yea or �No wit NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construcnan Standards and that a
frhis is a repair,fill out known well construction Information and explain the nature ofthe Py ofthis record has been providedro the well owner.
repair under#21 remarks section or on the hoc*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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/A SUBMITTAL INSTRUCTION
9.Total well depth below land surface: L•4 (ft-) 24a. For All Wells: Submit this font within 30 days of completion of well
For multiple walla list all depths ifdgerent(emmple-3@200'and 2@1001
construction to the following:
1 o.Static water level below top of casing:.. (ft.) Division of Water Resources,Information Processing Uni 110.St level is above easing use o •• rag Q
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition m 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 pushy eta.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Divlelon of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gum) Method of tat: AIR ROTARY 24c.For Water Supply&Injection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this forth within 30 days of
13b.DWDfeetlou type: Amount: ��O completion of well construction to the county health department of the county
where constructed.
Farm OW-1 North Ctrohiva Department ofEnvironmenbl Quality-Division of Water Resources Revised 2-22.2016