GW1-2022-10088_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD (rW 11 PrintForm
For Internal Use On y:
, I.Wdl Contractor Information:
CHRISTOPHER WATCHER
Well Contractor Name 14.WATEAZONES
`ROM TO DESCRIPTION
4448A g14 R 110 R 2
NC Wall ConuaeorCcniRadon Number R• R
CUMMINGS DEVELOPMENTS, INC 1S.OUTER CASING for in eased wary OR LINER I,-
FROM FROM TO DIAMETER
Company Nume H k R THICKNESS MATERIAL
65/e iR• .ISE 2•Well COmi1,I t11 n Permit#;—U 9 14 (./E1 N]2-2 1L IN NAR G,STEEL
CASDiG Olt TUBING WIRI HIR Closed too
4.v a(/app(iruble,w//ronrrruroon/X qll ( fDC,Cow �� TU
9'.Srafe,Parlvnre,elrf R DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): R. in•
Witter Supply Wen: R' R• ia.
Agricultural 17.SCREEN
❑MunicipaUPublic mom TO DIAMETER SLOTSM,
Geothermal mom
Supply) R. k. td THICKISIM MATERIAL
�Reaidenfial Water Supply(single)lndustliaVCommemial Residential Water SuPP1Y(shared)d) R'
ft..lrri Lion ia.
]E GROUT
NOHWeter Supply Well: PROM To MATERIAL
Monitoring 0 R 10 R EMPLACEMENT MErNOD 1 AMOUNT
n an: Recovery PORT.CEMENT POUR
R R
Aquifer Recharge ❑Groundwater Remediafiorl R• R
Aquifer Storage and Recovery Salinity Barrier 19•SAPID/GRAVEL PACK Ifs cable
Aquifer Test PROM TO MATERIAL O8mrmwater Drainage ft. ft. EMPLACEMENT METHOD
Experimental Technology
Geothermal(Closed Loop) Subsidence Control R _
Tracer A
Geothermal Hea' Coofin Return 34 D1D3.LING LOG attach add'tl 11 sheelaffnecm
Other(ex lain under#21 Remark, FROM To
D4SCRIi"rlON kolvq e¢r,n wlVroe4
4.Date Wells)Completed: R' R ttac,IN.)
'Z Z We11IDq
R, y�Sa.well LofLocation: ft.
R. ft.
�9rlioln.� � cl{n LI k.
Fac,ItlY/t)wTer name ft. „-
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FaeilitylDgfifepplieehle) R. � t'L•- �
7d9 R.
Ply IAJJ R. R. -
l\ I Cly JZp
r'TIr nn riYA cc R• k.
county _9931oµ2o? c H.REMARKg mof anPmcs8w4
Rrecl Idc-tirwatiun No.(PIN)
Sb.Latitude and longitude In degrees/minutes/Seeonds or decimal degrees:
(if--I[field,ono latlong h auRieicM)
j(o d 7 t7;73 d N — o Z 9 �Y7/ 22.Certlficatlo
W f
6.Is(are)the welt(,)OPermenent or ❑Temporary ,®„lure •1 —ZZ
Iflcd Wdl Connector
,;Is this a repair to an existing wen: OVes or ®No Date
ri15.4 ibis jargr,/bwxbv cenN .4C r2e-0200 wry(wart egqslRrelrd In mmd/,.I
"Poi it a e,#21,J/ff and IsITU ,veil ennrq'backq/gjarnmoon and crplain r/rr nulwr 0J'/h, -Py-0111 nxord has anmr prnwded to the nett aurrer.
avl/r/SA NCAC 0IC.0/00 or ISA NCAC 01C.f1100 Well Cmrahurpon SYagdards mid lbnr a
ropair wider,ll renmrks rrcrion or on the back ofMrs jm�m.
8.For Geoprobe/DPT or Closed- ermal 23.Site diagram or additional well details-
construction,only I GWA is needed. Indicate TOTALe1R hewing the same You may use the back of this page to provide additional well site details or well
drilled: NUMBER of wells construction details. You tray also attach additional pages if necessary.
9.Total well depth below land surface: /� SUBMITTAL INSTRUCTIONS
For mulriplr null'llrt 0/1deP1h1 ijdfQrrenr G..ramp/r-3Q100'mrdl©lag') (B•)
24a. For All Wells: Submit this farm within 30 days of completion of well
10.Static water level below rap of casing: 38 construction to the following:
/ju'ureNrv<I u abmw curing.,ur•v- (ft.) Division of Water Resources,Information Proeeuing l L Borehole diameter: 6 1617 Mail Service Center,Raleig(in.) h,NC 27699-ing Unit,
12.Well construction method: ROTARY 24b.For Infection -; In addition;o sending the folm to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,dlreel push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Infection Control Program,
13a.Yield(gpm) 2 1636 Mail Service Center,Raleigh,NC 27699-I636
—� Method of teat: AIR ROTARY 24c,�r Wate Suooly&lniectio 1 ;
In addition to sending the form to
136.Di
type; HTH the addresses) above, also submit one co of this form within the
days Amount: yac7 completion of well construction to Uo county health department of the county
where constructed.
Form GW-I
North Carolina Dcpattmcnt oravironmeMal Quality-D)vuion of Water Rnuumea