GW1-2022-02844_Well Construction - GW1_20220228

Print Form:,
-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM 'I'O DESCRIPTION
4448A ft. ft. W U4 I P 7
ft. ft. ? 2 73
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased,wells OR LINER if a `licab e
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. Li I ft. 6 in. PVC
Company Name
I',� �/7 16.INNER CASING OR TUBING epthermal closed-loop)
2.Well Construction Permit#: ,33^OI \\F Tn z I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC.County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'11Agricultural ®j Municipal/Public {t, g, in.
J 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: o ft. 20 ft. PORT.CEMENT POUR
:'Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
4.Date Well(s)Completed: �` " Well 1D#
5a.Well Location: ft. /O
c� 11 o e. 2
Facility/O Name Facility ID#(if applicable) 'Z ft. ft.
99og �;[\dy , Cy1�11 1A "� ft. ft.
Physical Address,City,an
ft. tt. F EB
921
G7n.2_7_7 5 jog f 21.REMARKS
County Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatfllo�n�g/is sufficient) t� 22.Certifica
3CID i� '3°� l t N �7 a O 01. I/! , W
6.Is(are)the well(s)> Permanent or Temporary �-at-c ell Contactor ate
form,I herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If 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 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 jto 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: �}� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,y VV (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1-7 (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 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
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: �®®'7- 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