GW1-2022-03043_Well Construction - GW1_20220228

" F Mt form
',- ?'WELL CONSTRUCTION RECORD (GW 1) For Internal Use Onty:
I.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4448A fe. ft. I
NC Well Contractor Certification Number ft. ft. Li G Li
15.OUTER CASING(for multi-cased'welUs OR LINER if a l livable CUMMINGS DEVELOPMENTS , INC FROM U DIAMETER Tx,cKNEs MATERIAL
Company Name +1 ft. ft. 6 in. PVC
2.Well Construction Permit#: h Q QQQ f7 �� 16.INNER CASING OR TUBING{eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
Agricultural FROM 'to DIAMETER SLOT SI%E THICKNESS MATERIAL
�MunicipaUPublic ft ft in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft.
Industr►al/Commercial Residential Water Supply(shared)
IS.GROUT
Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft.
PORT.CEMENT POUR
Monitoring Recovery fi. fL
Injection Well:
Aquifer Recharge E]GroundwatcrRemcdiation ft. ft.
Aquifer Storage and Recovery 19:;SAND/GRAVEL:PACK if a ticable
rY oSalinityBarrier FROM TU MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control rt. ft.
Geothermal(Closed Loop) OTracer 20,DRILLING LOG attach additional sheets if-------
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,solifrock e, rain size,etc.)
q 0 ft. r0 ft. O')
4.Date Well(s)Completed:1 Z Z?-21 well ID# 0 ft. y� ft. �L�
5a..Well Location: ft. tt.
-C H —bo'4-5 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft• ft. F
158 -Tro+ r +n, ft. ft. P1as 0us
Ph weal Address,City,and Zip 13ft. ft.
f1r!�n/_GI�I i 21.REMARKS
County ParcelIdentification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ' 22.Certifica'
35°%, -4 is N IV go 391 W
12-27-zI
6.Is(are)the well(s)oPermanent or OTemporary (gnat cnificd weii Contractor Date
y signing this form,I herebv certify that the well(i)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis Ls a repair.fill out/clown well construction information and explain the nature a/7he 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 NUMB of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS(ft•)
For multiple24a. For All Wells: Submit this form within 30 days of completion of well
wells lLrl all depths ijdiffe,•ent(eranple-3@200'and 1®!00')
construction to the following:
10.Static water level below top"
casing: 8
lfwate,•leve!/s above casing,use"p" (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 forme 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
f(i.e.auger,rotary,cable,direct pasty etc construction to the following:
g:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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: 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