GW1-2022-03004_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRI N ry ft. ft. y 2
4448A 2 4D
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 It, ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: F1A W� ZI L q -o22 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®j Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. in.
IndustriaUCommercial 13Residential Water Supply(shared) 18.GROUT
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft. PORT.CEMENT POUR
Monitoring EIRecovery
Injection Well:
Aquifer Recharge ft. ft.
Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Di Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test []Storlliwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
e. rL S0
4.Date Well(s)Completed: Well ID# ft. .�y ft. / �Lil�
r3monmil Jr..
5a.Well Location: ft. ft.
' tt 1—` - ( U c) ft. ft.
Facility/OwnerName 1 Facility ID#(if applicable) ft. ft.
H i r) l'_�U.mnll A.t I 00J�) FeA 21 -)Ja V ft. ft. kftmawn P
Physical Address,City,and Zip J I
t� ft. ft.
b q fb �0 U��0��!'Ou 21.REMARKS ,
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.Certific '
360 Z9-ZG 4 ' N W 4
I-q-u
6.Is(are)the well(s)o Permanent or Temporary Si re of Certified Well Contractor Date
By signing this form,1 herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EJNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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-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 ifdii fer-ent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: / 4 (ft.) Division of Water Resrces,Information Processing Unit,
if water level is above casing,use"+" an ou 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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(gpm) 5 Method of test: AIR ROTARY 24c.For Water Supply&Iniection 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: a'7 r�'Z. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016