GW1-2021-00452_Well Construction - GW1_20211222

_„WELL CONSTRUCTION RECORD(GW 1) ! 1 Print Form:
For Internal Use Only: -
I-Well Contractor Information:
CHRISTOPHER WATCHER
;14;*- ATER ZONES
Well Contractor Name TO4448A ft. faNC Well Contractor Certification Number ft• ft.
TER:,CASING;(for.multi-casedwells OR LINERi if.a livabl
CUMMINGS DEVELOPMENTS , INC TU DIAMETERATCompany Name ff 1'g ft 6 5/8 I in. .188 G.STEEL
2.Well Construction Permit#: 494A Q eL_3 2,1 16.INNER CASING OR TUBINNGE eothermafelosed400
TO KN MTER List all applicable well construction per•nats(i.e.UIC,County,Slate, Variance.etc.) FROM ft. ft. TER in. THIC ESS A IAL
3.Well Use(check well use): ft. ft. in.
rAgricultuial
Well: 17.SCREEN,
FROM TO DIAMETER SLOTSI%E THICKNESS aATERIAL
Municipal/Public ft. in.
(Heating/Cooling Supply) residential Water Supply(single)
ft.mmercial Residential Water Supply(shared) 18-GROUT
FROM TO MATERIAL D&AMOUNT
Non-Water Supply Well: 0 ft. 20 it. PORT.CEMENT POUR
EMPLACEMENT METHOD
:)Monitoring Recovery
Injection Well: ft' ft.
Aquifer Recharge Groundwater Remediation tt• ft.
Aquifer Storage and Recovery Salinity Barrier 19:SAND/GRAYELBACKlivable
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft. rr.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) O Tracer 20.1)RILLING';L<O'G attach addiHonalsfieets ifnecessa
Geothermal(Heating/Cooling Return) 10ther(explain under#21 Remarks) I FROM To DESCRIPTION Icoloq hardness,soiVrock e, rrin sirx,etc.r
ft. C)2 ft. J'
4.Date Well(s)Completed: Z Well ID# 92 rr. /ro g
9 4C
5a`.Well Location: ft. ft.
]pp c . r Gy f ft. it.
sn
F.. ity/Ow r Name Facility ID#(if applicable) ft• ft. y1 t u
51n DAe-11 VC� Z?21-7 ft. ft.
y�Physical Address,City,and Zip ft. ft.
b 0 u 9D( F211. EMARKS
County Parcel Identification No.(PIN) `Cilf
UNI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one lat/long is su cient)
I 22.Certification:
3�° 14'•l3o N -110 1q. 93o W
6.Is(are)the well(s)opermanent or Temporary �Sv
' antre of Well Contractor Daa signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15,4 NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthic is a repair,fill ont known well construction information and explain the nature of the c•oP.v of this record has been provided to the well owner.
repair under#21 remarks section or an the back oJ'dds 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:
�D
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS(ft.)
For multiple wells list all depths/fderenr(eranrp/e-9 c d00'and 2(u3100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
ffwater level is above casing,use'•+" (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,
/ 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
13b.Disinfection �� the address(es) above, also submit one copy of this form within 30 days of
type: HTH Amount: Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016