GW1-2023-01435_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 7
1.Well Contractor Information:
CHRISTOPHER WACHTER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. en rt. J
4448A n. ft. 3
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
CUMMINGS DEVELOPMENTS, INC FROM TO DI:UIETER THICKNESS MATERIAL
+1 ft. I'L 6 5i8 in. 788 G.STEEL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: dJ) !7 W Et Z2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County•State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. to
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single) t[ g, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft OW it' PORT.CEMENT POUR
Monitoring 13RecoveTy ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage rt. to
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
F'RO TO DESCRIPTION(color.hardness,wil/o k type,grain size,etc.)
Geothermal(Heating/Cooling Retum) nOther(explain under '21 Remarks)
e
4.Date Well(s)Completed: �0 %zaN WeB ID# e.
5a.Well Location: j
r��acet�,5
Facility/Owner ame Facility ID#(if applicable) ft. ft. _
3687r7 N NC- t Z- 411i�~ I�nla Z7211 '
Physical Address,City,and Zip p� n ftIli . ft. ]fli ftl 0.+3 1
�p�
O 001.5m�� / 21.REMARKS L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(t field,one tat/long sufficient) -7p q I 22.Certill
36U n:
U`1. 7 3 N a3t 7s W 10-27-VC
6.Is(are)the well(s)OPermanent or Temporary Si Certified Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or @No with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this,(orm.
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200''and 2@1001 construction to the following:
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Y2 AIR ROTARY g
13s.Yield(gpm) Method of test: 24c.For Water SuoDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /LTD 2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016