GW1-2022-08346_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 FROM TO DESCRIPTION
4448A «. it. w 0
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells OR LiNER if a licable
CUMMINGS DEVELOPMENTS , C FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft' 6 in. I PVC
Company Name
Loa
^ //��l�lJ�� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Loa , 0V tJ 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): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_,,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
Monitoring DRecovery ft. rt.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Rcmediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Oj Stonnwater Drainage k. tt.
Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _)Other(explain under#21 Remarks) FROM I AO DESCRIPTION(color,hardness,soillrock e,grain size,etc.)
rt.
4.Date Well(s)Completed: -I 1 -ZZ well ID# R. //® ft. A-v
Samtt
.Well Location:
V
`r\I k
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
q DPI (0 V S1 t `� �noy� rt. 1t.
Physical Address,City,and Zip
MAY 1
q 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if w/el-1 field,one IattAon-g7 is sufficient) 22.Certi6catio
31(JO0/7t3y / ' N 7% rb-17, W -11--z .7
6.Is(are)the well(s)0 Permanent or 13Temporary nature o ell Contractor Date
signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.fill out known well construction information and explain the nature ofthe copy ofthis 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: v (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'ands 2@1001 construction to the following:
10.Static water level below top of casing: ._? (ft.) Division of Water Reso bees,Information Processing Unit,
lfwater level is above casing,use"+- 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 Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /0,97_ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016