GW1-2022-02866_Well Construction - GW1_20220228

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_ WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM 1'O DESCRIPTION *f
ft. ft. l 6 V L.a•-f Z�y
4448A ft, ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR LINER if a ble
CUMMINGS DEVELOPMENTS , C FROM TO DIAMETER liva
THICKNESS MATERIAL
+1 ft. Lf ft. 6 in. PVC
Company Name I
t n 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERAAI.
I Agricultural ®I Municipal/Public ft. ft. in.
: Geothermal(Heating/Cooling Supply) V§Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_i (rrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. PO ft. PORT.CEMENT POUR
Monitoring ®Recovery
Injection Well:
_11Aquifer Recharge Groundwater Remcdiation ft. ft.
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Oj Subsidence Control
_j Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additionid sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typc,grain size,etc.)
O e. ft. O
4.Date Well(s)Completed: Well ID# rt. 720 G
5a.Well Location: 1 ft. tt.
SI t v1Lr U I ti} I D Le t?S ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3a t E•b T- . zcl t1�r 1��e b,.. a-� a. "7 ft. ft. pWGI�O(3
Physical Address,City,and Zip ft. ft.
N—Swe-L l OU7J - t21./REMARKS
County r Parcel Identification No.(PIN) Met
t L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica
ll 3 y��100 ��• O(J�'E. N 7 g(�(0 (✓ �' 1"L W
6.Is(are)the well(s)OPermanent or Temporary
Signat Ccrti red Well Contractor Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair.fill out known well construction information and explain the nature oflhe copy gjthis 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 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.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierenl(esannp/P-3@200'and 2@100') construction to the following:
10.Static water.level below top of casing: (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
ROTARY above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FIOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tJ -25 Method of test: AIR ROTARY 24c.For Water Suably&Iniectil n 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: 720 2 completion of well construction t i 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