GW1-2022-05937_Well Construction - GW1_20220627

��)I;L C®I�1S7I'H�UC�'yO1V RECORD((i;@1�/ fl) PrJnt Folii°
For Interlral Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
14:-WATERZONFS
Well Contractor Name :,: r>
FROM TO UESCRIP7'ION
44448A fr. ft. 9
NC Wcll Contractor COrtiricatton Number ft• ft.
CUMMINGS DEVELOPMENTS, INC 1s.0UTERCASING(formulti=eztseii,wells)[`UR°,LINER ifs FROM TO DIAMETER THICKNESS
CompaayNnme +1 ft. IL MATERIAL
2. 6 6/8 In• .185 O,STEEL
Li Well CoDstuui Permit#: 53�,f10 LJtL�1Z2 I6s°INNERICASING:OR:TUB IIVG eothcrin�fclosed=too ..' `
List all applicable ivevcll consUtrrtion pe.wtllr�,e.U1C,County,State,Parlance,etc) FROM TO DIAMETER "
ft. THICKNESS MATERIAL /
3.Well Use(check well use): ft. in,
Water Supply Well: ft. rr ;n
"17:SCREEN!:
Agricultural Municipal/Public FROM ro mnalErtiR sLOTSIZE
Geothermal(Heating/Cooling Supply) ngle) ft. ft. in THICKNESS ATERIAL
PP Y) ®Residential Water Supply(si
Industrial/Commercial Residential Water Su I ft. D• io.
IrrigationPP Y(Shared)
Non-Water Supply Wel➢: FROM TO
Monitoring a ft. 2e f6 _ = EMPLACEMENTME'ROD&AMOUNT
Injection W Recover PORT.CE AT POUR
ell: 9 13
Aquifer Recharge ft. ft.
Groundwater Remediation n• %
Aquifer Storage and Recovery Salinity Barrier "19'SANDD/GRAVEL PACK;if a"Reab)e
Aquifer Test FROM TO MATERIAL
StornrwaterI)rainage ft. % EMPLACEMLNTJ3%JE7HOD
Experimental Technology �
Geothermal(Closed Loop) Subsidence Control ft
O Tmcer 20:DRILLINGLOG attach addlHbnal;`8—a''if necess
Geothermal Heatin Cooling Return} Other(ex lain tinder#21 Remarks)
FROM 7'O DESCRIPTION teotor,riardn sNVrock e, rote she,
4.Date Well(s)Completed. �,—I__ 2 7 tt, ft. etc.)
•�. Well INft. � %Sa.Well Location:
h• ft.
ft.
Facility/Owner Name Facility ID#(ifapplicable) ft.
i-It-I o15 0,SSe-r Fr n^c Jar it. fL
D`Ysica+nuuress City and zip
p . f. L
`2l.REMACo4yM �t SDO c g OQ v
_ -
Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,Ono laylong is/Sufficient)
1 22.Certite on:
N� �D<�yZ w
6.Is(are)the well(s)apermanent or OTemporary ignoturo of z�
ell Contractor Date
7Pltis.IS this a repair to an existing well: Yea or q�^{ ing this fawn,I heilebv ceduy tliat the wells)Ivas(weir)cons atrcled in accordance
epah IT a erpab;JIl[ort!knave well conslrtrclla®oraallon and p/ain the near ojthn raPy ojthNCACO2C.0100Il�t ov �Co C�u 11 ot�� ell ConshvreNon Mandads and that a
trpalr under#21 remarkssectlai or on lire back ofthlsjora.
3.
Sit
am or
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 2 o may
use theback of thisal Page fo weli r Provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL You etaP g P
drilled: NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 400 SUBMITTAL INSTRUCTIONS
Fa ntultlPIP wells list all depilns ijd perm'(ixantple_3 a@200 and 2Q1001) (f t•) 24a.EKA1 Wells:
Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following:
ljtvaterleve!is above castes rim'•+^ (ft.)
Division of Water Resources,Information Processing Unit,I1.Borehole diameter: 6 (in.) 1617 Man Service Center,Raleigh,NC 27699-1617
ROTARY 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
12.Well construction method. above,also submit one copy of this fore within 30 days of completion of well
(i,e,auger,rotary,cable,direct push,etc.) construction to the following:
[13a.
WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
Yield(gpm} 1636 ti'1an Serice Center,Raleigh,NC 27699-1636
Method of test: AIR ROTARY 24c.1 ar Water SuoDly&Injection *!ells, the form to
Disinfection type: HTH i the address(es) above, also submit one copy of this r form on to sending
0 days of
Amount: Q completion of well construction to the county health department of the county
where constructed.
Fenn GW-I
North Carolina Department of Environmental Quality-Division of Water Resources