GW1-2022-05951_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPT ON
4448A ft. ft. :r
ft. ft. & t Cos
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wel(s OR LINER if a Iicable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft
Company Name +1 6 in. •f e i,
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 5 I Le 4 wG-u- Z` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State,Variance.etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ]S.GROUT
Irrl ati.n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge nGroundwatcr Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storn water Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock e, rain size etc.)
ft. J ft. Li s 71
4.Date Well(s)Completed: Well ID# ft. 2,0,3 ft. ! ��
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N 7 .nn
fJIq (1)oodu"br. C'lralr\ay.,-_ ft. ft.
Physical Address,City,and-lip ft ft. tit
gs gaga&& 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) q 22.Certifica'�
3L o o3c DQ iis f N 3 -0 az-j oz' W
6.Is(are)the well(s)0 Permanent or 13Temporary Signatur ertified Well Contractor bate
By signing this farm,I herebv certify that the well(s)was(were)constructed in accordance
C 7.Is this a repair to an existing well: []Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200/Yell Construction Standards and that a
Ithis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this font.
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: SUBMITTAL INSTRUCTIONS
9.Total well ft.depth below land surface: t�tl
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmltiple wells list all depths ifeliferent(exannple-3 n 200'anndd�2Q100') construction to the following:
10.Static water level below top of casing: !I (ft.) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use'•+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /2 Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection type: HTH Amount:
the address(es) above, also submit one copy of this form within 30 days of
f% 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