GW1-2022-10089_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD GW-1 Print Forn
For Lrtemal Use Only.
L Well Contractor Information:
Christopher Wachter
Well Connector Nsme K.WATERZONBp
FROM To pg�jlpD�
4448A R. e.
NC Woll Couhaetar Couiaealloe Number R• R.
Cummings Developments, Inc. IS.OUTER CASING fw in eslul wegsi ORLINER if
FROM TO DIAMETER TnICKNEIS MATERIAL
Company Name +1 R. ft. a in.
n PVC
2.Weli Construction Permit#:_�D13 (a eLNZI FROM ER CASING OR TUBING(mmermal oloutldoo
3.1 adwe l use(c/e'wit,well use):
111(Lt.VAC;Caen FROM TO DIAMETER TWCLO)ESS MATERIAL
N.dYale,Fm•(unre.ale) h R In.
3•Well Use(check well use):
Water Supply WeB; R' (t in.
Agricultural 7.3
QMunloipidthblic FROM TO DIAMETER SL(my,.'ds TNfCKNESB MATERIAL
Geothermal(Heatlng/Coolieg Supply)
®Residential Water Su I (e) R' R. In.
InduatxiaUComtnercial ppy(sin E R.
OResidential Watm Supply(shared)
Ini tion Ii.GROUT
NoD-Water Supply Well: MGM T° MATERIAL RMWCEMENn'MEI7IOD AM Monitoring 0 R. uNr
. 20 R• Pon Cemsnl Pour
Injection Well: Recovery
2
Aquifer Recharge ®Groundwater Remcdiation °' R.
Aquifer Storage and Recovery ®Salinity Barrier 19•BAND/GRAVEL PACK
Aquifer Test FROM TU Is
®Sromrwater Drainage R, MATERIAL EMPLACEMEWMETROD
Experimental Technology QSubsidence Control
Geothermal(Closed Loop) a, rL
QTracm eothermal(Hretin 20.DRILLING LOG attach additional sheets If necessary)
G Coolin Retum) Other(explain tinder#21 Remarks) FR°M TO DEaC1lIY ION rotor.berenwr,,Wumsa ra size,s,e,)
4.Date Well(s)Completed:
Well ll)# R. � R.
IL Well Location: L
R. ft
Facdity/OwmrNmo Faeflity lDY(lfepplk:able)
-
PhpigiAd�Ma,Clghaod3'!p R. R.
�1-t o xn rn.County F& "!4 a�LN 39 21.REMARKS
vta10'30G
Panel Identifleation No.(PIN)
Sb.Latitude and longitude in degrees/mimdWumads or decimal degrees:
(if well field,one Ia llong is sufficient)
N�9° -7Q• 745 22.Carderatie
W -ZO-7JL
6.Is(an)the weil(a)IMPMvranent or 13Temparasy a' taro ofCortlfla C
Dam
7.Is this a repair to aD existing well: Yes or NO BY slxn(r folnr.I hereby co ijry that the"Its)Mn(were)caru0uded In accoadancr
JNi,t.u rePdn fll(au known well emuuwetln®nformel(on n®xplain Ne naume n n ca�Y nJ'tA'rCrACO2ha x1�yrnSAX M the aril m00 Well Caulrud(an&elldard,and/hat a rrpa/r under#2!remarkraecllno w an r/rn back oJ'Ihlsforur.
S.For Geoprohe/DPT'or Closed-Loop 23.Site diagram or additional well details:
p Geothermal Weal having the same You may use the back of this page to provide additional well site details or well
construction,ined Only 1GW1 it needed. Indicate TOTAL NUMBER ofwells drilled: construction details. You may also attach additional pages if accessary.
9,Total well depth below lsnd surface: / 7o SUBMITTAL INSTRUCTIONS
Fornultlp/exelh Batal/depths(ldjgrrenl(eeediple•3@200•mrdl®/0p1 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
-1 10.Static water level below top -7 conatmctian to the following:
p of casing;_ 5;x
ffrwrrr loyal(,ahavrcasinE usr^+^ (ft.) Division of water Resources,Information Processing Unit,
It.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699.1617
(In.) 24b.For Infection Welts: In addition to sending the from the address in 242
12.Well eooatructiaD method: Rotary m toabove,also submit one copy of this form within 30 days of completion of well
0-auger,rotary,cable,direct puck,eta) construction to did following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13s.Yield(gpm) Q Method of test: Al'Rotary 1636 Mail Service Center,Raleigh,NC 27699-1636
_
24c. For Wat_ Sounly&Injection Wall.. In addition w sending the form to
136.Disinfection [L// the address(es) above, also submit one copy of this form within 30 days of
��. HTH Amount: /7c�Z completion of well construction to the county health department of the county
where constructed.
Form GWd North Carolina Depamncnt of Environmental Quality-Divisim,of Wince iteaa n
Revised 2.22.2016