GW1-2022-02868_Well Construction - GW1_20220228

i WELL CONSTRUCTION,RECORD GW Print Form
w For 111MI-Hal Use Only: - - -
1.Well Contractor information: -
CHRISTOPHER WATCHER
Well Contractor Namc - 14i WATER}-ZONES;
FROM TO DESCRIPTION
4448A ft. ft. f
NC Wdl Contractor Certification Number {t• tt. l
CUMMINGS DEVELOPMENTS, INC FROMUTER#CASING(for,multieeased-wells rORLINER•i iCO- livable
TU DIAMETER THICKNESS MATERIAL
Company Name ft. L.
6 5/811 In. fag G.STEEL
2.Well Construction Permit#:�Z'j tt eothernial closed400
INNER CASING OR:TUBING,
List all applicable IveycmnoneNon permrts Carnty,State,r7adanc•e,etc.) EOM ft. TO DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): in.
ft. ft. in.
EGCOthermal
y Well:
n18.:SCREEN�
l E]Municipal/Pub)ic FROM To DIAMETER SLOT SIZE 'THICKNESS MATERIAL
(Heating/Cooling Supply) residential Water Supply fr.
t ft.
rn
omme{vial PP y(single) {tResidential Water Supply(shared) 18..GROUT`
FROM -- _ .`,...: _ .- r_•,
Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring 0 ft. 2e ft. PORT.CEMENT POUR
Injection Well: Recovery
ft. ft.
Aquifer RechargeGroundwatcr Rcmediation tr• ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if:a 'llcable) ,
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
ft. [t.
Experimental Technology
Subsidence Control e,
Geothermal(Closed Loop) R
Tracer 20i,DRILLING1 G'attach additional!sheets If ticcessa
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) httOM To
DFSCRIPTION SEEM hardness,sail/mek e, rain srrx,cM.)
cc ft.4.Date Well ft. 8 11
s)Completed: �Zp"
Wc11ID# � ft. 1 R.
5a.Well Location:
Facility/Owner Nam c
e_ Facility iD#(if applicable) ^7 ft. ft. C D r C D
Physical Address,City,and Zip
t�7 ai� 1 R• ft. r
�` ft. ft.
0 DQd 11:REhfARKSr. "
County111" (��45700 O pB�' © _ _ .
Parcel identification Na.(PIN)
5b-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
36i_'S• 9
1y N M rS 21 G6/ 22.Certittca
7 •�6.Is(are)the wells) permanent or Temporary 1 G -27- 2l
gaature c � ell Contractor
Date
7.is this a repair to an existing well: Yes or �'.vigniag llni,fornr,I herebi,centif than the well(.r)was(mere)constructed in accordance
Ijthis is a re air, Ill out kronur reel/consn7cction1 fa7aation and i lain the nature nfthe p. f this recant!has been provided to the nel/owner.
p f with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Construction Standards and that a
repalr under#21 remarks sectiar or on the back of this form, p copy v n
m or
8.For Geo robe/DPT or Closed-Loop Geothermal Wells having the same You
may
e he back of this apagelto Provide additional well site details or well
p P You ma
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 40 SUBMITTAL INSTRUCTIONS
!or realflp/e wel/•c list all ifdi(ferent(eranrple-3(11200•and 2@10-0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:_d 1 construction to the following:
!!water•!evens above casing,use + (ft.) Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method: ROTARY 24b.For Infect_ io_n Wtells. In addition to sending the form to the address in 24a
(i.e.auger,rota above,also submit one copy of this form within 30 days of completion of well
g rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gPm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: AIR ROTARY
24c.For Water SunI &Inieetion!Wells: In addition to sending the form to
13b.Disinfection type: HTH the address(cs) above, also submit one copy of this form within 30 days of
Amount: A Z completion of well construction to the county health department of the county
Form GW-I a where constructed.
North Carolina DcQartmcnt of Environmental Quality-Division of Water Resources
Revised 2-22-2016