GW1-2022-06545_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14:,.wATERzoNEs
Well Contractor Name FROM TO DESCRI ION
4448A ft. ft. MW 4 15 '
it.
NC Well Contractor Certification Number U�
A5;O.UTER:CASING.(foeifoulli easediwells_ORrL NER�ffie Hcable r
CUMMINGS DEVELOPMENTS , INC FROM Tu DIAMETER THICKNESS MATERIAL
Company Name In, .188 G.STEEL
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'16:INNE&CASING ORNT UBING 7"'eo'therinel closcfl=loo `�, �2.Well Constriction Permit#:�s FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construrtion petmtty ft.e.UIC,County,State,Variance,etc) ft. R. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17l;SC I EN," - _
Agricultural FROM TO DIAM in SLOT 81%E THICKNESS MATERIAL
� �Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. In.
Industrial/Commercial Residential Water Supply(shared) ,
.1S.,GROUT
_!Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT. Non-Water Supply Well: 0 1t 20 h•
PORT.CEMENT POUR
Monitoring _'Recovery ft. ft.
Injection Well:
Aquifer Recharge E3Groundwatcr Remediation n' ft.
Aquifer Storage and Recovery Salinity Barrier t'19.tSAND/GRAVEti PACK'lf,a Nabl, _
FROM TU MATERIAL EMPLACEMENT METHOD
Aquifer Test OStOrmwater Drainage ft ft.
Experimental Technology Subsidence Control ft R
Geothermal(Closed Loop) Tracer i Z0+DRILL'ING'LOG:"a`tiach•adi tflonalshe`ete if nec'essa _ _
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks FROM TO DFSCRIPTION teeter,hardness,90111me.k e, rain size,etc.)
ft. %
1
4.Date Well(s)Completed: _ZZ Well FD# Y7e. 00 It.
5a.Well Location: ft. ft
r� a�r5or1 it. ft.
Facility/Owner amc IVFTY
Facility 1D#(if applicable) n• ft
ya Old iG ova�� L� ,o�u; ft.
Phhylsical Address,,City,and Zip ft. -ft.
1. a sw eA1 0O FS 0 Z 5- _37,REMARKS4:;, ',' P Ut1�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 41. 22.Ccrtificat'
6.Is(are)the wells)J Permanent or oTemporary S' re of Certified Well Contractor Date Z Z
7.Is this a repair to an existing well: 13Yes or JMNo By iltr15ArNCAC 02C.0100 or 15A/fy NCAC 01C.0200 Well Conslritct athat the well(s)was(werc') n Standards and accordancetcled at a
If thiv iv a repair,fill ont known well constrtrdion information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of thisforin.
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: / ®0 SUBMITTAL INSTRUCTIONS(ft.)
For multiple wells list all depths if different(example-Al 100'and 1©100'► 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Stade water level below top of casing:__
1lwarer level is above casing,rise +^ (ft.) Division of Water Resources,Information Processing Unit,
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,
1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water SuDDIv&Iniectlo�Wells: In addition to sending the form to
o b the addresses) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 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