GW1-2022-05944_Well Construction - GW1_20220627

s��iPr<int�Form=
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER ,:. . .--
i14ibWATERZONES _= = -
Well Contractor Name FROM To DESCRIPTION
4448A ft' It '70-75 '2
ft. ft.
NC Well Contractor Certification Number }ISS'OUIIER''CASING::(fnii iieulh cesedlwells,QR LINERI i$`a IIcalile
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. I ft 6518 In. .188 G.STEEL
- --
INNER,,t ASIIVG':UR':TUB11VG1 eotliecma4elos@d=1ou
2.Well Construction Permit#: rJa�1 g W E LN 2_Z FROM To DIAMETER THICKNESS MATERIAL ^
List all applicable wetl consh trctiou per rnitr(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: -17'.SCREEN .=GROUT-- .
-
Agricultural LE THICKNESS ------
DIAM481,
ETER THICKNESS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared)
Irrigation MPLACEMENT METHOD&e44I0UNT
Non-Water Supply Well: 0 ft 20 ft.
PORT.CEMENT POUR
.Monitoring nRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation it. ft
Aquifer Storage and Recove i39:,SANDIGRAYEL P,AC&-ifa'licable —
ry 13Salinity Barrier' FROM TO MATERIAL EMPLACEMENT 11IETHUD`
Aquifer Test [3Stomiwater Drainage ft fa
Experimental Technology oSubsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20:iDRILLINGLOG attaetitadditlotialfsheetslif Iiecessa );`?- _
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solurock e, rain size.etc.)
ft. ft '
4.Date Well(s)Completed: ~22 Well ID# 100 ft _
Sa.Well Location: ft. f1.
t'F�r14t�L� I�v`2tS ft. ft.
Facility/OwneMame ♦ r�pFacility ID#(if applicable) D• ft. MN rd
5!)3 7 {--1(i V b�-� V112.a.,� I Y `��0.i�.i. ft. ft. a:•a•�Fii�".sI^,,.:':..•
Physical Address,City,and Zip ft. ft.
�hn r�✓v c� 9 1?I I) `1 Yo o 0 _21t RELViARKS:.. _ -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or
deci
mal
mat degrees:
(if well field,one lat/loug Is ufficicnt)
g
r es:
I 0 �01 � 22.Certificati
— (a N �� I�� W
,accordance
6.Is(are)the wells) Permanent or Temporary ignatumm of I ell Contractor Date
igni
7.Is this a repair to an existing well: E]Yes or JMNo with ISAiNCAC 02C.0100eo-ISAbv iNCAC 02Clfy that the.0200 Well Cons/niclion Standavelks)was,(were)constructed rds and that a
#'/big Le a repair,fill out known well construction information and explain the nature copy thn o o l
repair under#21 remarks section or on tire.back of Uds form. j this record has been provided to!be well owner.
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:
A 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j(/multi
ple (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
multiple wells fist all deptlns/jdperenl(erannple-3ca 00'and 2(Q/0')
construction to the following:
If water level is above casing,use •+'
Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If '
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24h.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,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection e• HTH the address(es) above, also submit one copy of this form within 30 days of
tyP • Amount:/Qr9Z completion of well construction to the county health department of the county
where constricted.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016