GW1-2022-05935_Well Construction - GW1_20220627

`WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER �11:WATER4ZONES4 r:. .7_`,
Well Contractor Name FROM TO I DESCRIPT ON
4448A ft. ft. (0)20
NC Well Contractor Certification Number ft. ft. w)-8.7 Z
15i:;OUTER CASING(for',multi=ceseel*6Us"X.1INER+ Vd6-Ocable -:; . -
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS I MATERIAL
Company Name +1 ft 2 ft. 6 5/8 Im• .188 G.STEEL
�.1�t ;1b.,INNERtCASING'.:OR,T,UB1NGi' eofhetmakdtised-rote'1.�. . _
2.Well Construction Permit#: c 1pt /;� A�Q'(� FROM TO DIAMETER THICKNESS MATERIAL^
List all applicable well construction pervuLs(i.e.UIC,Comity,State,Varianee,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN`:' -
Agl'1CU1tW'a1 FROM TO DIAMETER SLOTSILE THICKNESS' MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 12Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation 18:_GROUTr, - -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft. PORT.CEMENT POUR
MonitoringRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
tL fL
kr
quifer Storage and Recovery49 FROM:,SANDLGRAVEL PACK if
licali[e f
� EMPLACEMEN Salinity Aquifer Test [3Stotntwater Drainage ft. TO ft T11fETNUD
MATERIAL Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILL'ING,LOG1 attaeli dditlonal=sheetsiif<necessa _'
FROM TO DESCRIP ION[colon;hardness,soldrock Je, min slze etc.]
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks)
ft. /2 f4 -
do
4.Date Well(s)Completed: Well ID# ft.
fL '19
�/►CO%1 S�
Sa 2 -7 /1 G'
Well Location: y—�t 22 27 ft-
ft.
S ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft• —ft -e• 1 a
19 JK� rt. ft.
Physical Address,City,and Zip ft. ft.
L� I D --;21t,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)
/ 22.Certiflcatio Z
6.Is(are)the well(s)oPermanent or 13Temporary gnature of 'r Well Contractor Vale
B ong this farm,I hercbv ce"Oy than the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or IgNo with 15A NCAC 02C.0100 or1SA NCAC 02C.0200 lyell Consh teclion Standards and that a
lfthis is a repair;fell out know"well construction information and erplabr the nature of Um copy of this record has been provided to the well owner,
repair under#21 remarks section a•on the.hack 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 NUMBER of wells construction details. You may also attttch additional pages if necessary.
drilled:
3 L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 Fa (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
r multiple wells list all depths (eraurple-3@200'and 2Q 100')
construction to the following:
#' Static water level below tap of casing: (ft.) Division of Water Resources Information Ifuater level is above casing, "+" o ratio g , n 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 olle 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) Method of test: AIR ROTARY 24c.For Water Sumoly&IniecHon 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: 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