GW1-2022-02839_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW-J) For Internal i at use Only: h
I.Well contractor Information:
CHRISTOPHER WATCHER 14.�.WATER
-
Well Contractor Na mc � ,_.-—Wi _7
FROM TO DESCRIPTION
4448A
NC Wcll ContractorCertification Number ft• ft.
f&FOUTE&GASiNG, or ffinin'-da"setif e
0 iR RR MR`
Altapp
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 66/8 1 in. 41 G.STEEL
SINGJOR..ITUBING' �_ 'eOI-c'sed'66'
,c 0
2.Well Construction Permit#: WtSl WC-L�)2_1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CoUnly,State.Variance,etc.) ft. ft. in.
3.Well use(check well use): • in•
ater upply Well:
S
FROM TO DIA51FTER SLOTSIZE THICKNESS MATERIAL
rAgricultural DMunicipaltPublic ft. ft. in.
Geothermal
en
Geothermal(Heating/Cooling Supply) Residential Water��pply(single)
I u t i i ft. ft. in.
Industrial/Commercial E]Resideniial*ater Supply(shared)
I I .
.R tio
nigation GROUT
FROM TO MATERIAL
Non-Water Supply Well: EMPLACEMENT METHOD&AMOUNT
Monitoring 0 ft- 20 ft. PORT.CEMENT POUR
Injection Well: ecovery ft
ft.
i Aquifer Recharge E]Groundwatcr Reme'diation ft.
Aquifer Storage and Recovery DSalinityBarnier
FROM TO
Aquifer Test MATERIAL EMPLTC—EMENTMETH61)
Experimental Technology oStormwater Drainage; ft. ft.
13Subsidence control
Geothermal(Closed Loop) OTracer GX
on e Ff-necessal
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION Icolor,hardness..H/
4.Date Well Completed: Z-'I- -Z W,IIID# :fff=ft.
52.Well Location:
LFT_ Cpft-Ayucjo"_ ft.
Facility/Owner Name Facility ID#(if applicable)
I R Z O NUR V\h.L.
Physical Address,City,and Zip ft.
REMARK&a M
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,One laViong is sufficient)
22.Certificati
c' 0 3.9 N W
6.Is(are)the well(s)oPermanent or oTemporary ignat Cc r
led Well Contractor
Date
signing this form,I hereby certiA-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with l5ANCACO2C.0100or' 14 NCAC 02C.0200 Well Construction Standards and that a
V'Ihis is a repair,fill out known well consiniction information and explain the nature qfthe copy of this record has been provided to the well owner.
repair underbi remarks section,or on the back of this form.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to I provide additional well site details or well
construction,only I GW-I 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:
(ft)
For multiple wells list all depths if different(example-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:
if water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,I Raleigh,NC 27699-1617
11.Borehole diameter:-6 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction meth ROTARY above,also submit one copy of this 'oil: 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
erground Injection Control Program,
1636 Mail Service Centir,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY
24c.For Water S
uptilly&Injection Wells: In addition to sending the form to
HTH the address(es) above, also submit orie copy of this form within 30 days of
13b.Disinfection type: Amount: 1/001?— 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