GW1-2022-06434_Well Construction - GW1_20220511

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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 I DLE, IPTI SCRON
4448A -1
fit. ft. (Cc`
i J ✓`�// f�`�
1`
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER if a► liable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS I MATERIAL
Company Name +1 ft. fit. 6 5/8 in. .188 G.STEEL
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: 5a 8 3 W ez M z.2- FROM TU DIAMETER I 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. fit, in.
r
upply Well: 17.SCREEN
I(UI'aJ FROM TO DIAMETER SLOT SI%E THICKNESS MATERIAL.oMunicipal/Public ft inrmal(Heating/Cooling Supply) ®Residential Water Supply(single)
ial/Commercial Residential Water Supply(shared)
18.GROUT
in- ate FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fit. 20 ft.
PORT.CEMENT POUR
Monitoring Recovery fit. fit.
Injection Well:
Aquifer Recharge QGroundwater Rcmediation ft. fit.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(i a licaltle
OSalinity Barrier FROM TO MATEf RIAL EMPLACEMENT METHOD
Test OStormiwater'Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional!sheets if necessary)
r
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(coorr,hardness,stiff/rock type.grain size,etc.)
ft.
4.Date Well(s)Completed: �k'—� Well ID# fit. J� ft.
5a.`Well Location:
)e sS►c a �p I�al 1 t� ft. ; - ft.
Facility/Owner Name Facility iD#(if applicable) n• f^ ft.
Physical Address,City,and 21p + fit. tt.
I--tt amo_t'�L-L 98,?�b S 8$ry 21.REMARKS
County Parcel Identification No.(PIN) W
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) /
Z j ` 22.Certi
•� 'f / /J'/ fic n•6.Is(are)the well(s)o Permanent or 01remporary Signature o ild Well Contractor Date
signing this farm,I hereby certify that the wells)was(were)conso•rrcled in accordance
7.Is this a repair to an existing well: Elves or JMNo - with ISA NCAC 02C.0100 0r ISA NCAC 02C.0200 Well Consntction Standards and that a
fthi.Y LP a repair,fill out known well conTh"'clion information and explain the nature 0f1he Copy 2fthis record has been provided to the well owner.
repair under#21 remarks section or on the hack 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: —(ft-) 24a. For All Wells: Submit this fo;;m within 30 days of completion of well
For multiple wells ILrI all depths if different(example-Sea 200 and 2Q/00q
construction to the following:
If water!eve!is shove casing,use"+Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
!f "
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
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) f ' Method of test: AIR ROTARY 24c.For Water Supply&lniection Wells: In addition to sending the form to
13b.Disinfection type:
HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: r 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