GW1-2022-05909_Well Construction - GW1_20220627

'WELL CONSTRUCTION RECORD (GW-J) For Internal use only:
1.Well Contractor information:
CHRISTOPHER WATCHER
4."WATERIZOi NE�g
7.
Well Contractor Name FROM 1.0 DESCRirl101N
4448A ft. ft. 4
NC Well Contractor Certification Number ft. ft.
�F-
KC-XSJN 0L
CUMMINGS DEVELOPMENTS , INC FROM -E or
V.1(f6r lti;lciis-e e - INE WiFalili
DIAMEIER THICKNESS I MATERIAL
Company Name +1 ft. fL 6518 In. .188 G.STEEL
--16.1NNEWC,ANING1:0K_T.UBIN fi j, --
6f(-iF0ih;1fr alt 7 di d;.I
2.Well Construction Permit#: iij, ,r
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well"Onsicitcli"11'ellnit-T 6.e.UIC,Colinty,State,Variance,Cie.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water supply well
�aoM TO DIAMETERSLOT SIZE THICKNESSMATERIAL
:)Agricultural 13Municipal/Public ft. ft. in.
:]Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) ft ft. in.
:)Industrial/Commercial E]Residential Water Supply(shared) A8.14
Jlrrigation ----------
Non-Water supply well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 it. 20 ft.
nMonitoring PORT.CEMENT POUR
Injection Well: DRecovery ft.
:)Aquifer Recharge DGroundwater Remediation ft. ft.
:JAquifer Storage and Recovery DSalinity Barrier F.-19'.%SAND/,GRIAVELIPAG-K!(I*f,-2 P-fili—
cable),
,MENT ME
Aquifer Test [3Stormwater Drainage FROM ft. TO ft. MATERIAT"' "jgiW��IjTH 6D6
Experimental Technology E)Subsidence control ft. R.
Geothermal(Closed Loop) On2cer
12 0i'DRIBLIM3'�L;O
lGeothermal(Heating/Cooling Return) I Other(explain tinder#21 Remarks) FROM TO DEqu up
,Ay-zz- ft. 7 gI ft.
4.Date Well(s)Completed:1—1,70 Well ID# 17ri ft. 1 0 ft. 0
5a.Well Location: ft. Co
ft.
Facility/Owner Name
Facility ID#(if applicable) ft.
ft.
7 2022
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN) 00'
5b.Latitude and longitude in degrees/minutes/seconds or decimal de2rees-
(if well field,one lattlong is stificicrit) 22.Certific
350§6, q29 N —-7 W 4111
6.Is(are)the well(s)oPerinanent or oTemporary Sign 0 Certified Well Contractor Date
By signing thisforni,I hereby cerlify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes orEJNo with 15A NC,4C 02C.0100 or 15.4 NCAC 02C.0200 lVell Construction Standards and that a
V'lhis&a repair,fill oat known well construction information and explain the nature qfthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or an the back of this forlil.
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 I 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:
For
24a. For All Wells: Submit this form within 30 days of completion of well
Multiple wells list all depths ifdifferelit(kw;nple-3@200'.d 2Q�1-001) - construction to the following:
'I 10.Static water level below top of casing: 0
(!water level is above casing use"+- (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:.6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Infection Walk 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)--Le�— Method of test: AIR ROTARY 24c.For Water Suooly&In"ection'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: R-01, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016