GW1-2021-00460_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW 1) Print Form
For Internal Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
r 14:WATER ZONES -
Well Con ha m
ctor Nac FROM '1'O DESCRIPTION
4448A ft.
NC Well Contractor Certification Number ft• ft.
15.OUTER',CASING(for rmulti-cased Lvells)=Olt LIN if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER ERTHICKNESS MATERIAL
Company Name +1 ft' ft. 65/8 m, 185
G.STEEL
2.Well Construction Permit# 5641 LA El.N Z ' 16,INNER CASING OR:TUBING: eofhermal closed=loo ;
FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction pernats�.e.UIC,Corarty,State.Yiviance,etr.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSI7E
Municipal/Public ft. ft. in. THICKNESS PIATF.RIAL
:]Geothermal(Heating/Cooling Supply) JRResidential Water Supply(single)
J hrdustrial/COmmercial ft• ft. in.
Residential Water Supply(shared)
hri ation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft.
PORT.CEMENT POUR
_ Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Rcmediation ft' ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licable)
FROM TU MATERIAL Aquifer Test E)Stonnwater Drainage ft. ft. EMPLACEMENT METHOD
Experimental Technology Subsidence Control a• ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach'additional A ets•(f necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DF.SCRIPTI 'fcoW,hardness,selYnck type,gmin size,etc.)
n f p rt. 2— ft.
4.Date Well(s)Completed: ! \ Well ID# z ft. ft.
G
Sa.Well Location:
Facili wncrNamc Facility ID#(if applicable) ft. ft.
1
21
159 5 e ��a.-� �� vl i :� e77a17 rt.
Physical Address,City,and Zip ^� ft. ft. t
r'
County
L 23"1701p 3C)�I� 21.REMARKS a
C
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient)
3/� /� {�•1� A� I� n 22.Certificatio
b�OL• TJV N _ �w eLd . age W J /
6.Is(are)the well(s)opermanent or 13Temporary nature of 'ied Well Contractor I Da c
ance
7.Is this a repair to an existing well: E]Yes or EJNo withr15AtNCAC 02C.0100 Or ISArNCArCt 02C.0200the ivr/l(v)1Vell C.o»sh"ctionwas(were) tucted Standardstand ccorthat a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well ouvrer.
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 1 GW-)is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
y
9.Total well depth below land surface: l/ SUBMITTAL INSTRUCTIONS(ft.)
For multiple wells list all depths if different(axn»rple_3@200 and 2�100) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: ft.)
If water level is above casing,use"+ e ( Division of Water Resources,Information Processing Unit,
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
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 push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2, Method of test: AIR ROTARY
24c.For Water Supply&IniectionlWells: In addition to sending the form to
13b.Disinfection type: HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: / O Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016