GW1-2022-06543_Well Construction - GW1_20220511

I
iWELL CONSTRUCTION RECORD GW_I --
For Internal Use Only: r.. Pnlnt;'FOfrr
1,Well Contractor InfolTnation:
CHRISTOPHER WATCHER
Well Contractor Nam 14. TER ZONES
4448A
FROM TO DESCRIPTION
6 ft.
NC Wdl Contractor Certification Number
CUMMINGS DEVELOPMENTS , INC ✓L rt.
5:OUTEUTER'++CASING'(forinulH
FROM ?eased, ens OR LINER':if_a livable
Company Name TO DIAMETER
+1 ft. X.p ft. THICKNESS MATERIAL
.188 O 6 5/S in.
2.Well Construction Permit#: I�I b 3 16.INNER;CASING OR TUBING, eo closed=lao G.STEEL
thermal-
List all applicable well earth arlion permit.,r.e.UIC,Comrty.Slate,I1artanre,ea•.) FROM TO
� DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): ft' ft. in.
Water Supply Well; R ft. in.
Agricultural lb:•SCREENi
0Municipal/Public FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
ft. in,
IndUStrial/Commercial PP y( g ft.
Residential Water Supply(shared) ft in.
Irri ation
78t.GROUT
on PPIY Well: FROM T-Water Su O
nitoring a ZD ft. � -
MATERIAL EIIIPLACEME,NT METHOD&AMOUNT ft.
ejection Well: Recovery
rt. rt. PORT.CEMENT POUR
Aquifer Recharge
@Groundwater Remcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier -19.1 SAND/GRAVEL PACK Wit livable):.
Aquifer Test FROM TO E3Stom MATERIAL
ftlwater Drainage EMPLACEMENT METHOD
Experimental Technology ft.
Geothermal(Closed Loop) Subsidence Control
H. ft:
G OTtacer
eothermal(Heatin Cooling Return) 20::DRiLLING10G'attach'addit(onal sheets itnecessar
Other(explain under#21 Remarks) FROM To DEfS ION rnmq hardness,soiVmck e, rain s
4.Date Well(s)Completed: O— Wc11ID# ft. Z/ ft. frx,crr.>I 1
2�5 -Well Location: H. ft. a(J)C
ft• ft.
F ciliry/Owner Name e� ft ft.
/+ Facility ID#(if applicable) ft. ft.
el
r 0. C,YQVL (- ft.
Ph siiccalAdd ess,City,and Zip Q ft.
ft. ft. Ufl�
County 21.REMARKS'
Parcel Identification No.(PIN)
5bi Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lat/long is sufficient)
(0 ,R0j1s N ot� /�� � i 22.Ce ti
71 (.r.)the well(s)aiernianent or OTemporary Si g c of Certified Well Conhactor
7.IS this a repair to an existing well: �pgYes or Date
@J 1§No By signing this jornr,I lrerehv cei7tfy'that the well(v)was(here)consnvmted in accordance
rep s is a repair fill ant known well carsn•Uctian Information and erplain the natare o/t/m c opv q(this record has heea provided to Ctil wet!owner.
with I SA NCAC 02C.0100 or/SA NCAC 02C.0100 Ne!!Carsh nctah Standards and that e
irP +'under#2/remarks sectla»a•oil the back oj-ihis.(orm.
t;.F r Geoprobe/DPT or Closed-Loop Geothermal Wells having the same y use the back of this page to provide additional well site detail
23.Site diagram or additional welidetails:
con.-ruction,only 1 GW-1 is needed, hldicate TOTAL NUMBER of wells You ilia
drill d:--------------
�/ �f construction details. You tray also attach additional pages if necessary.
s or well
9.Tdtal well depth below land surface: /Qtf SUBMITTAL INSTRUCTIONS
Ivor• Fulliale welly list all depths Irdierent(eranrple-3 rr 200•and f(r41—oo') (ft-)
242. For AID Weds; Submit this form within 30 days of completion of well
10.Static water level below top of casing: 15 J construction to the following:
!twat•rlevells above casing,use + (ft.) Division of Water Resources,Information Processing Unit,
11.B Grehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method:
ROTARY 246.For Iniection Wells: In addition to sending the form to the address in 24a
0-c.a er,rota above,also submit one copy of this form within 30 days of completion of well
g rotary,cable,direct push,ere.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a. field(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
to
'Method of test: AIR ROTARY 24c.For Water$uDDly&Iniection Wells: in addition to
136.t�isinfection type; IiTFI the addresses) above, also submit one COPY of this Form sending
30edayst of
Amount: 360 y. completion of well constriction to the county health department of the count
where constructed, y
Form G -1
North Carolina Department of Environmental Quality-Division of Water Resources
Rcviscd 2-22-201 C,