GW1-2023-01441_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
CHRISTOPHER WACHTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft ft s JTq
ft. ft
NC Well Contractor Certification Number INC15.OUTER CASING for multi cased wells OR LINER if a licsble
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. z9 ft 6 5/8 in. .188 G.STEEL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' 51 U 7 W ELtCl 42 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. It. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS NI,NT FRLV.
Agricultuml [3MunicipaMblic ft. ft. in,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&ANIOUNT
Non-Water Supply Well: R. �ln ft. PORT.CEMENT POUR
Monitoring DRecovery ft. OC(l ft.
Injection Well:
Aquifer Recharge Groundwater Remediation tt.
19.SAND/GRAVEL
GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage % ft.
Experimental Technology QSubsidence Control ft. ft•
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUruck is rain size,etc.)
O « fL Ip
4.Date WeH(s)Completed: ^(` Well 1D# /l2 ft. tt 0 CAC
5a.Well Location: ft. ft. o ,-- .a ;.
L"-4"e ft. It.
Facility/Owner me Facility ID#(ifapplicable) ft. ft -= "
3IAG M N L_ Le 2 "�W t w Dry a-73o ft. ft. �_.-- PmnCOiNiUl;:t
Physical Address,City,and Zip Q21
ft. ft.
=gV16 8g$741q 0lo-17 21.REMARKS
County Parcel identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one flat/long is sufficient) q f 22.Cert' a
340 09. I�yl N ,1� Z3-L' i W I
6.Is(are)the well(s)OPerma lent or 13Temporary gnature of ied Well Contractor Date
By s' Ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or FJNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
/fthis is a repair,fill out known well construction information and explain the nature o copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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' 139.0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -�`� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent texample-3@200'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
11.Borehole diameter: 6 (in.) 24b.For Injection 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
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Injection 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: 2 at 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