GW1-2022-02847_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW 1) PrintFo�rn
For Internal Use Only:
i
if-Well Contractor Information:
CHRISTOPHER WATCHER
14i'WATER ZONES
Well Contractor Name FROM 1.0 UESCRIPTION
4448A S(� rt. C ft.
NC Well Contractor Certification Number g ft ft.
CUMMINGS DEVELOPMENTS , INC FRUM15. UTER.GTSING(for mUDIA-ME.DIAMETER
`O THICKNESS a II MATERIAL
Company Name +1 ft.
ft. 6 518 rn 188
1 +-lcl w G.STEEL
Z.Well Construction Permit#: !b� w� -1�+ -, 16.INNER CASING OR TUBING eat closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable)vell con.4n•uctianPel7nits(1.c.UIC,County,Slate,f7ariance,etc.) ft. ft. in.
3.Well Use(check well use): in.
Water Supply Well: 17:SCREEN:
:]Agricultural FROM TO DIAMETER SL01'SI%E THICKNESS n1ATF.RIAL
Municipal/Public ft.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single)
ft. ft. in.
IndustriaVCommercial
Residential Water Supply(shared) 19.GROUT
JN
Uri ationFROM TO MATERIAL EMPLACEME METHOD&AMOUNT
on-Water Supply Well: o tt 20 rtNTPORT.CEMENT POUR
Monitoring Recoveryjection Well: rt. ft.
Aquifer Recharge @Groundwater Rcmediation ft• ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if a licable}
EMPLACEMENT METHOD
FROM TU MATERIAL
Aquifer Test [3Stonnwater Drainage ft. g,
Experimental Technology Subsidence Control rt. g,
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional she if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,saiVroek e, rain svx,etc.)
aft, 31 ft. a
4.Date Well(s)Completed: —Z� +ZZ Well ID# 31 ft. g, L
5a.Well Location: ft. ft.
ft. ft.
bacility/OwnerNamc ;Facility lD#/(�fapplicable) rt• ft. FEB 2 ME
ft. Pt ss�11t0
Physical Address,City,and Zip t ft. ft.
C 'C_ p 17 17 7 1 Q t� C 21.REMARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient)
22.Certific o
W 1-Zo-ZZ
6.Is(are)the well(s)oPermanent or oTemporary rgnaturc c ificd Well Contractor Date
•signing this foray,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: InYes or EJNo with 15A NCAC 02C.0/00 or, ISA NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature afthe c'0PY ofthis record has been provided to the well owner.
repair under#1/remarks section or on the back oJYhis 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-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: (ft.)
For„rrr/tip/e wells list all depths ifdUJere»t(era»rPle-3@2 0'arrd 2(a)I00') 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:/!water level is shove casing,use (ft.) Division of Water Resources,Information Processing Unit,
"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6
24b.For Iniection 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,
�J 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: AIR ROTARY 24c.For Water Suouly&Iniection'Wells: In addition to sending the form to
13b.Disinfection e: HTH /� the address(es) above, also submit one copy of this form within 30 days of
type: Amount: !Gr 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