GW1-2022-02848_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW 1) Pint Form-
For Internal Use Only:
i1.Well Contractor Information:
I
CHRISTOPHER WATCHER
14�WATER:ZONES
Well Contractor Name FROM TO DESCR ON
4448A ft. ft.
ft. ft.
NC Well Contractor Certification Number
._15-OUTERiCASING'forimulh cesedw.wetls`OR LINER=if,+a`licatil'e CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft 6 5/8 In• 788 G.STEEL
I r -16i INNEIt;CASING OR'�TUBING eotherin'al'`closed loo_ tx -,+� °:.;..
2.Well Construction Permit#: -'E IL)CL�a a FROM TO DIAM`ETER THICKNESS MATERIA-xL
List all applicable well construction permits ri.e.UIC,County,State,Variance,ere) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.ISCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
i Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
18 GROUT
-'Irrigation t
FROM TO MATERIA &AMOUNT
L EMPLACEMENT METHOD
Non-Water Supply Well: o k, pD R.
PORT.CEMENT POUR
:)Monitoring Recovery ft.
Injection Well: ft.
:)Aquifer Recharge [3Groundwater Rcmediation ft. ft.
Aquifer Storage and Recove 79:'-SAND/GRAYELTACK;'if 8 °licaBle
rl' Salinity Barrier FRUM TU MATERIAL EMPLACEMENT"'MOD "
Aquifer Test [3Stormwater Drainage fa ft.
Experimental Technology [I Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20:DRILLING;LOG attscti=additioriiilsheetaaf:necessa
Geothermal(Heating/Cooling Retum) _ Other(ex lain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rock e,�rain size,ctc.l
ft. z 3 ft. 3
4.Date Well(s)Completed: 1"2 Z Well ID# J? ft. /p ft. _
5a.Well Location: ft. ft. CI
ft. ft.
Facility/ wncr Name Facility 1D#(if applicable) ff• ft.
S tr ft. ft.
Physical Address,City,and Zip ft. ft. P
I�APL MN"y, o O O 0 3 Q 0_]q`i 3 .21'REMARKS - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long igsufficicnt) 22.Certif ti
02
J� •airs N �.70 ZS •7`Z'
W
6.Is(are)the well(s)oPermanent or Temporary S' lure of Certified Well Contractor Date r Z
By signing this form,I herebv cc/-/-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis Loa repair,fill out known well construction information and explain the nature ofthe 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 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:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
V (ft.)
For multiple wells list all depths if different(eramrple-3 a 200-and 2Q100') 24a. For All Wells: Submit this form within 30 days of completion of well
`, construction to the following:
if water level is above casing,useStatic water level below top of casing: log (ft.) Division of Water Resources,Information Processing Unit,
Ij "+"
1617 Mail Service Center,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 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 WE LS ONLY: Division of Water Resources,Underground Injection Control Program,
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: 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