GW1-2022-02870_Well Construction - GW1_20220228

E
sin' t Form T
•WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
FROM 't'O DESCRIPTION
Well Contractor Name
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a livable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER' THICKNESS MATERIAL
+1 ft. iY-5 ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 17 7 O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. +11,
in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM 'I'O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) tt. fr. in.
_,Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_J hTl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft PORT.CEMENT POUR
Monitoring ®Recovery
Injection Well:
:)Aquifer Recharge nGroundwatcr Remediation
19.SAND/GRAVELft.
PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stomiwater Drainage
Experimental Technology OSubsidence Control
_I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION!color,hardness,soil/rock e, rain sire,etc.)
® f1. ft.
4.Date Well(s)Completed:1 Z-fib-Z 1 Well ID# 7 1 ft. o ft- /U U�t
5a.Well Location: ft. ft.
skx.✓� FEW MIJ
ay
Facility/Owner Name n Facility ID#(if applicable) ft. ft.
55Q Mo-w.� G\O rN 2.1 a L4 L{ ft. ft. EB
ft.
Physical Address,City,and Zrp ft. pm U11111111,
27.REMARKS WOMP
County \ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certi6cafion
3G°)7r 53y/ N 79°Z( •/67' W
6.Is(are)the well(s)0 Permanent or 13Temporary ofC 4mi,1,15A"
rc 'r well Contractor Date
ing thisform,I herehv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No NCAC 02C.0100 or 15A NCAC 01C.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 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: /a (ft•) 24a. For All Wells: Submit this t form within 30 days of completion of well
For multiple wells fist all depths ifdiiferent(example-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,
!!water level is above casing,use"+., 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
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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m(gp ) � � Method of test: AIR ROTARY 24c.For Water Supply&IniectionWells: 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: �QD Z completion of well construction to i the county health department of the county
where constructed. f
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016