GW1-2022-02842_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW 1) T 'Frint;;F,orrn
For Internal Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
14:WATER ZONES:
Well ContractorNamc FROM 7.0 UESCRIPTION
4448A ft. ft. . 1 I
NC Well Contractor Certification Number ft• tt. 3 32 7 3 c 2— 3 5 H
CUMMINGS DEVELOPMENTS , INC 15.
OUTER CASINGCTSING(for m DAMEERens OR CKNESS a hMATERIAL
Company Name 2 +1 ft. H ft. 6 6%8 in. .188 G.STEEL
2.Well Construction Permit# } 7 L f♦�'Z 1 16.INNER CASINGOR TUBING. other gal
FROM TO DIAMETER THICKNESS List all applicable well construction pet[nits(i.c.UIC,County,State,Variance,etc.) ft. ft. in, MATERIAL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN
Agricultural FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
[MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercialft•
Residential Water Supply(shared)
Irrigation ]S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:_J Monitoring Recovery o ft- 20 ft. PORT.CEMENT POUR
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remcdiation ff ft
Aquifer Storage and Recovery Salinity Barrier 1%SAND/GRAVEL PACK(if a. licalit
FROM TO MATERIAL EMPLACEME.. METHOD
Aquifer Test [Stonnwater Drainage
Experimental Technology [Subsidence Control
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessa.):
Geothermal(HeatingtCooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION[color,hardness,soiuraeutype. rain size,etc.)
© ft. 3 t7 It.
n .J
4.Date Well(s)Completed: 2-1 I well ID# � ft.
5a.Well Location:''
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 1
2a.'S3 ft. ft. FEd
Physical Address,City,and Zip ft. ft.
a `�'�`f��7 21.REh1ARKS )
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
Q � 71 N _7 c q� -7 22.Certificatio
� � �O.� C W
6.Is(are)the well(s)oPerinanent or [Temporary Sig tiro ofC• red I Contractor
Date
7.Is this a repair to an existing well: [Yes or MNo 'si ig this form,l herebv ceWify'hat the wells)was(were)constructed in accordance
1f this is a repair,fill out knotm ivell construction information and explain the nature of copy of t)is record has
en 00 provided
tov d d to ISA th�K well owner.
re00 m Well Construction Standards and that a
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS_ >(� (ft.)
For mulnple wells list all depths ifdi,/ferent(erantple-3@200 and 2@1001 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If Static water level below top of casing:__ y (ft
If water level is above erasing,use'•+'• f`-'-- ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 (in) i
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,
/Z 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: 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: Zc Z completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016