GW1-2021-00454_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
FROM TO I DESCWl�IOIN
Well Contractor Name
4448A fL ft, v
NC Well Contractor Certification Number 15.OUTER CASING-(for multi-cased wells OR LINER tf a nicotine
CUNNINGS DEVELOPMENTS INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 618 In. .188 G.STEEL
Company Name ate` 16.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#: 4,311 WGLIM z-1` FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
ft. ft. in.
3.Well Use(check well use):
Water Supply FROM 1 Well: R SCREEN
OM '1'O DIAMETE OT SI%E 'THICKNESS atA"fER1A1.
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT -
_ Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. PORT.CEMENT POUR
I Monitoring _J Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL_RACK ifa licable)t
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft'
Experimental Technology nSubsidence Control ft. Ct.
Geothermal(Closed Loop) OTracer 20:DRILLINGLOG(attach additiodal sheets if necessary)
FROM TO DFSCRIPTION(color,hardness,soll/reck e, rain size,etc.)
Geothermal(Heating/Cooling Cooling Return) Othef(explain under#21 Remarks) ft, L14 It.
4.Date Well(s)Completed: 15 2 Well 1D# 4 y ft. ft'
Ct. ft.
5a.Well Location:
L"�� ft. ft. ..� ..
Moles to r N. � _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Mk c`:� cam. ,�d sbt ft. DEC 2 2021
ft. ft.
Physical Address,City,and Zip
Q><VKW�-Q *I—I�0 �a0(a S 8 2E.REMARKS 1 1
Ir
KAI
County Parcel Identification No.(PIN) , 1rN P',* c�SSM UNr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is syfficient) 22.CertificAk4—
/Signature
340 50- 6z N ` 1° IS t-185 � W - -ZI
6.Is(are)the well(s)OPermanent or Temporary
crtific I Contractor Datc
his n,I hereby certify drat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or EJNo 02C.0I00 or ISA NCAC 02C.0200 Nell Construction Standards and drat a
Ifthis is a repair.fill out known well construction information and explain the nature oftheecord has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. agram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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: �n 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 a/l depths it different('example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!!water level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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,1 Underground Injection Control Program,
FOR WATER SUPPLY qLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&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: completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016