GW1-2022-06260_Well Construction - GW1_20220628

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I WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft. I (De7 it. 1 6 JP in. I Wng-ow t Vp
-�C Cl6.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: - _I 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 SLOT SIZE THICKNESS MATERIAL
Agricultural ra �MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
ustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [J Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
RFROM TO DESCRIPTION(color,hardness,soil/rock e, rain si x,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ® ft. /_� ft. o
il
4.Date Well(s)Completed: Well ID# ft. ?QO ft. d
5a.Well Location: �C
ft. ft.
/ ce Otte 11
Facility/Ck6erName Facility ID#(ifapplicable) ft. ft. `'` "a-$•-
ft. ft.
Physical Address,City,and Zip (� �f 7.J�
//�L✓tr^ 97/�� /t�� 21.REMARKS Inv,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient)
lD Z�t N �0 �'�� W 22.Certifica
t[7 z
6.Is(are)the well(s)�Permanent or Temporary Signatur cd Wcll Contractor Date
y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: InYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#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 1 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: 0 0 -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@2W and 2@100) construction to the following:
10.Static water level below top of casing:9I (ft.) Division of Water Resources,Information Processing Unit,
If ivater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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) Method of test: AIR ROTARY 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
�J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: !10o7, 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