GW1-2022-05949_Well Construction - GW1_20220627

WALL CONSTRUCTION RECORD(GW
For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER
UVAT-EK-DONES
Well Contractor Name FROM I TO DESCRIPTION
4448A It. ft. SPS1
NC Well Contractor certification Number ft. ft. 114
1 S�,0 UT E R C A S I N G,If 6 ri I ft a I a-'eld i c d Lm e 4 0'0CiIi'
CUMMINGS DEVELOPMENTS , INC FR OM To DIAMETER THICKNESS MATERIAL
in.
Company Name +1 6518 .188 G.STEEL
EL CASING.'ORJUrTl I
2.Well Construction Permit#:
L4 Ly 0 TO DIAMETER THICKNESS MATERIAL,
List all applicable well consirnetion pernils(i.e.UIC, State,Varlanre,ere)
ft. ft, in.
3.Well Use(check well use): ft. n. in.
Water Supply e 17-!SCREEW__-;.
Agricultural
FROM TO DIAMETER BLUE SIZE THICKNESS MATERIAL
[3Municipal/Public ic ft. ft. in.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
Industrial/Commercial - nResidential water supply(shared)
Irrigation
• Non-Water Supply well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
D 0 & 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Igjeenon Well: ft. ft.
Aquifer Recharge E)Groundwater Remediation ft. ft.
Aquifer Storage and Recovery OSalinity Barrier i,'i19.,ySAND1GRAVEL7.PA- Via''litsib
FROM TO MATERIAL
Aquifer Test 138torniwater Drainage ft. ft. EMPLACEMENT METHOD
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop.) 13Tracer ZO LING.1 Gi art"WAdditidi
Ge
othermal(Heating/Cooling Return) m Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness soi0racic e,'rain slu eh.l
ft. fL
4.Date Well(s)completed:!L —ZZWll 1D# 0
wpzdt
5a.Well Location: J tt. ft.
aeA y
k AcA —ft. it.
Facility/Owner Name Facility ID#(if applicable) ft•
ft. j— 7-7
k .y U.'_1 '. K__LJ
ft. ft.
Physical Address,City,and Zip ft. ft.
OrA c_m a_n_r,(?- �2I'.,REMARU,__:i_
County —f-14—
Parcel
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is 3tifficient 22.Certifl
_32_� a 'q ' N -79'9 Z1,331 -1.1
6.Is are the well(s)OPermanent or oTemporary Signature of 23—ZL,
tic c I Contractor Date
7.Is this a repair to an existing well: Yes or MN ring My form,I hereby certify that the'vell(s)was(Were)constructed it:accordance
Phis LT a repair,fill on
know),well consrilclion 0 with ISA NCAC 02C.0100 at-ISA NCAC 02C.0200 lVell Construction Standards and that a
remarks section or on the hack of illisforin. copy ofthis record has been provided to the well owner.
repair under#211 information and explain the nature of floe
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: /Zo SUBMITTAL INSTRUCTIONS
(IN 24a.for All Wells. Submit this form within 30 days of completion of well
Far nuritiple wells list all depths if different(example-3@200 and 2@100.)
construction to the following:
10.Static water level below top of casing:
If water level is above casing.use"+" _—&—_ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:.6 (in.)
24h.For Iniection 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.YieldAIR ROTARY
(gpm) Method of test: 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:ZZA—Z 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