GW1-2022-05936_Well Construction - GW1_20220627

` -in Form=
.°I ELL CONSTRUCTION RECORD (GW-1) or Internal Use Only:
1.Well Contractor Information: \`�
CHRISTOPHER WATCHER
U.WATER;ZONES'.Well Contractor Name .. FROM TO DESCRIPTION '
4448A A,; k. ic. I (elf 1(07 2-102-S44 l
ft. ft. ?
NC Well Contractor Certification Number
IS:OUTER`CASING•(fdr'multi;casedwells.9RiLINER;ifa 7icable CUMMINGS DEVELOPMENTS , INC FROM TU DIAMETER THICKNESS MATERIAL
Company Name +t ft. 6 m. PVC
g�1 '' '.\\ ,d6.INNER,CASI1NG'OR=TUBINGI eothermal closed4bo
2.Well Construction Permit#:_3.3 a Lk)��,z FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction pernnts(i.e.UIC.County,State•f"ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN:.
FROM TO DIAMETER SLO'1'SI'LE THICKNESS MATERIAL
Agricultural [IMunicipal/Public R. ft. in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft. ft. in.
Indusnial/Commercial Residential Water Supply(shared)
3S..GROUT'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
A uifer Recharge ft. ft.
9 l; �Groundwatcr Remcdiation
Aquifer Storage and Recovery ty 'Salini Barrier 19.SAND/GRAVEL.PACK if•a licible)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20:DRILLiNG;LOG attach:additional+rheefs!ifnecessar`)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,soul—t, e. rain size,etc.)
ft.
4.Date Well(s)Completed: Well ID# ft. ft.
15� ; `G
Sa.Well Location: ft. It.
® 1 \ f A
Q 1� a ft.
Facility/O i Name ` + ` Facility ID` (A
#(if applicable) 7- ft. ft. Jl
A 1 m Y1m ft. ft.
Physical
�Address,
,City,an ft.
( ft.
�-7� S 10 1 ;21.;REMARI{S;
County Parcel Identification No.(PIN) inier ..-.r. RPP Q Z I Inil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. ✓s' 'e;
(if well field,one lat/long is sufficient)
��
22.Certifica
� off , �
J A� N 7! ®�• t®I W
6.Is(are)the well(s)OPermanent or ElTemporary gnauue crt i Well Contractor Date
•signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ONo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200{fell Construction Standards and that a
/jthis is a repair,fill oul known well construction information curd explain the nature oflhe copy of this record has heell provided to the will owner.
repair corder#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.(GW-1 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 For i nultlple wells list all depths/fdierent(eraniple-3Q200'and 2Q100') of completion of well
construction to the following:
fwaler level is above casing,are'•+'•
10.Static water level below top of casing: 1-7
(ft.) Division of Water Resources,Information Processing Unit,
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
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(g m} . AIR ROTARY
P Method of test. 24c.For Water Supply&Injection Wells: In additi
on to sending the form to
13b.Disinfection type: HTH v the address(es) above, also submit one copy of this form within 30 days of
Amount:_3®t7, completion of well construction to the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-201 G