GW1-2022-06432_Well Construction - GW1_20220511

PrJntTForm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.,WATER=z0NESL
1'ODESCRIPTION
Well Contractor Name FMum DESCRI Pl'lON
4448A ft• it'
NC Well Contractor Certification Number
3 ft. tt.
.•ISS OUTER;CASING:fo:m6lti-ca`sediweBs OWL'INERI(ifia Rcalile ;
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +t ft. G� ft.
6 188 G.STEEL
1C.,INNER:CASING:0R,TUBING "eothtrittiil closed=loo t � .2.Well Construction Permit#: —Tb 3� In�LN Z Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,Stale,Variance,etc) ft. ft, in,
3.Well Use(check well use):
Water Supply Well: 17i;SCREENi`
-
Agr1CU1tU1'al FROM '1'O DIAMETER SLOTSI7.E THICKNESS MATERIAL
��Municipal/Public ft. f. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) _
_ Irrigation FR,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AM6UNT
• Non-Water Supply Well: c ft. 20 R
PORT.CEMENT POUR
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwatcr Remediation ft. fL
Aquifer Storage and Recovery _ p� ;19 SANDIGRAYEI.PACK•'if e" llchb 0"
�_pSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Storinwater Drainage ft. R
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILI4ING`I' GA attiichtad'diilonal sheets`af;n@cease
Geothermal Heating/Cooling Return) _;Other(ex lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock e,grain size,etc.)
ft. r ft
4.Date Well(s)Completed: -29-ZZ Well ID# Xd
C Il. fL
5a.l Well Location: it. iL
�G�t� rn d Py ft. ft. /
Facility/ Name Facility ID#(if applicable) It. ft.
...» .
_In1�llt� I�� '�d ��tk �- �. ft. MAY 1 1 2022
Physical Address,City,and Zip g, ft
(NA ' q p
'�11C1IV�0. ,-L<.+ i 9Q� z 1 S/�O a :21::REMARKSi i!
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
3�0/�, G ZZ 22.Certific '
6.Is(are)the well(s)oPermonent or Temporary ignaturc o crtificd Well Contractor Date
signing this form,I hereby certify that the wells)was(were)constructed hr accordance
7.Is this a repair to an existing well: Oyes or JMNo with 15A NCAC 02G.0l00 a 15A NCAC 02C.0200 Well Gonsmrct/on Standards and that a
Ifthis is a repair,fill out known well caastrrtclion information and explain the nature of the -Py ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of Nds forrn.
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:
9.Total well depth below land surface: rd 0 SUBMITTAL INSTRUCTIONS
(ft.)
For multiple webs list all depths iifd different(example-3@200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
�2— construction to the following:
10.#'ivnterleve!is shove casing,rise Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
Ij
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.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&Iniectio on Wells: In addition to sending the form to
13b.Disinfection HTH the address(es) above, also submit one copy of this form within 30 days of
type: Amount:�d1?z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016