GW1-2022-05933_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14sawaTERzoIVI ;.
Well Contractor Name FROM TO DESCRIPTION
4448A 4 loft. 6 V &
ft. ft.
NC Well Contractor Certification Number
15 OUTERtCASING;(foeiatulfi?ciisedEwells)tUlf LINER?ifia Rcatile
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 141 It. 6518 in. 168 G.STEEL
i-16:+INNERiCASiNG:OR`TUBING;: eothe`rma4dose8=lbo` "' '
2.Well Construction Permit m 5.P78 Wl LN 2-Z FROM To DIAMETER THICKNESS MATERIAL List all applicable well construction penniLs(i.e.UIC,County,State.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ..17'-SCREENI.= •ti ---
Agricultural PROM TO DIAMETER SLOT SI%E - THICKNESS-_ MATERIAL
E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single)
��Mi ft. ff. in.
Industrial/Commercial _ Residential Water Supply(shared)
-
_i Irrigationat FROM TO MATERIAL J' EMPLACEMENT METHOD&AMOUNT Non-Water Supply well: 0 ft- PO ft.
PORT.CEMENT POUR
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier %79:SANDIGRAYEGIAACK•'rfa"' -_
FROM TU MATERIAL _ EMPLACEMENT DI ETHUD
Aquifer Test [3Stotmwater Drainage ft fo
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer ,20;DRItiI:INGLOG.attadi,addlilotialfsheets iEne¢e`ssar , -
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,salUrock e, rain slrx,eh.l
6� ,/ ft. 's ft. 1
1
4.Date Well(s)Completed: 1�'`7 y 2-2- Well ID# s ft. I r-( ft. Q 1
5a.Well Location: ft. S it. ( 1��n l�Ac,J
ft. $ ft. v
Facility/Owner Name Facility ID#(if applicable) ft. ft
I9Ip 5 L• _ -_ .
Physical Address.Cit a6d Zip' '-' ft. ft.
lu<n f1CP 877RI YZS !RENARKS'::.'_ _ _ __ _ ::)„ q;r;) ra_
County `+,fma"i lIBOG
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
322.Certifrc n:
S�SS e 3�1za N ��°a2G-1�7, W
are /�✓�z( (s)Permanent or Temporary igna rficd Well Contra
6.Is )the wellctor Date
By signing this form,I hetebv certify that the wells)Was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or I§No tv/th ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Constrtrctfon Standards and that a
Iflhis it a repair,fell orrt known well construction information and explain the nature of the copy of this record has been provided to Nu•well owner.
repair under#2I 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well de
SUBMITTAL INSTRUCTIONS
Fa depth hero
p w land surface:- b D (t•) 24a. For All Wells: Submit this form within 30 days of completion of well
r multiple wells list all depths/jdderent(examp le-3 a 200'and 2Q/00') f
�� construction to the following:
If Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water love!is above eosins rise"+"
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,
/f_ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) W Method of test: AIR ROTARY 24c.For Water Supply&Infection Wells: In addition to sending the form to
136.Disinfection type: HTH
the address(es) above, also submit one copy of this form within 30 days of
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