GW1-2022-02975_Well Construction - GW1_20220228

i
WELL CONSTRUCTION RECORD (GW l) For Internal Use Only: Print Form
I.Well Contractor information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM '10 DE CRIFHON
4448A ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a Iicable CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. I ft' 6 5/8 In. .188
G.STEEL
1 - A� r117.
INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: (� Co-- OM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C•,Comity,State,-Variance,etc.) ff
ft. ft. in.
3.Well Use(check well use): ft. k. in.
[Geothermal
r Supply Well: SCREEN
cultural FROM 1'O DIAMETER �LOTSIZE 'THICKNESS MATERIAL
Municipal/Public ft. ft. in.
(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
In Residential Water Supply(shared)
ation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. pD ft.
Monitoring Recovery PORT.CEMENT POUR
rt. rt.
Injection Well:
Aq itiferRecharge Groundwater ft. tt.
Rcmediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a Iicable)
QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStornwater Drainage ft. ft.
NExperimental Technology E]Subsidencc Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 10ther(explain under#21 Remarks) FROM To DESCRIPTION[color.hardnew,soil rock type,grain Size,etc.[
ft. C;V ft 1
4.Date Well(s)Completed: 2- 10-Z Z well ID# — ft. tt.
dt
5a.Well Location:
ft. ft.
Facility/Owner Tame ` Facility iD#(ifapplicablc) it• ft.
Physical Address,City,and Zip q ( 7 It. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
Jk �q. n� N �J �, 22.Certifica
/Y _�7 �d . ���
2-I6-2Z
6.Is(are)the well(s)1M Permanent or oTemporary urc of Certified Well Contractor Date
By.signing this form,1 herebv certify that the urll(s)was(were)constructed in accordance
7.is this a repair to an existing well: Yes or @No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
!this is a repair.Jill out known well contraction inJortnation and explain the nature of the cow of this record has been provided to the well owner.
repair under#21 remarks section or at the hack of this jotm.
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:
/r'�U/1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (�
For nudtiple wells list all depths ifdifjerent(example-3@200'and 2 a 100') 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: Sb
/ftvarer level is above casing,use"+" (ft.) Division of Water Resources,information Processing Unit,
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
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,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Qr(/Gi 1L Method of test: AIR ROTARY 24c.For Water Supply&Infection 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: D completion of well construction to the county health department of the county
where constructed.
Fort GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20 16