GW1-2021-00459_Well Construction - GW1_20211222

E �Print Form
iy E 1,CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor information:
CHRISTOPHER WATCHER
141. ZONES
Well Well Contractor Name FROM TO UESCRIP'1'ION
4448A ft• rt. �3
NC Well Contractor Certification Number ft 7t.
15.OUTER.CASING(for multi-cased wells OR LINER if a ble CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS lica MATERIAL
Company Name +t ft. �1 ft. 6 5/8 1n. 188 G.STEEL
2.Well Construction Permit#: $b(a p IilELN 7- I 16.INNERCASING.ORTUBING' eotherma[closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction per•nuts(i.e.UIC,County,State,Mariance.etc) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
Agricultural FROM 'ro DIAMETER SLOTSr7w THICKNESS MATERIAL
�MunicipaUPublic ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
J IndustriaUCommercial Residential Water Supply(shared)
Irri ation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft.
PORT.CEMENT POUR
Monitoring Recovery
Injection Well: ft. rt.
Aquifer Recharge Groundwater Remediation ft• ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a licable)
E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT ilfETHOD Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessar
vi
Geothermal(Heating/Cooling Return) _I Other(explain under#21 Remarks) FROM TO DESCRIPTION Icoloq hardness,--frock e, rain sbk,etc.)
d rt. ft. �
4.Date Well(s)Completed:ILA--A Well ID# / it. .Z d ft. aCj(
5aa..Well Location: t ft.�..J�t� I�.1/✓]U� ft. ft. 1�1
Facility/OwncrNamc Facility ID#(ifapplicable) ft• ft.
aIy I ¢ ft. Ur f
Physical Address,City,and Zip p r� ft. ft.
21.REMARKS' 11"
County ..
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
_ . •l� 22.Certific n:
(�Z N DO 17-QUM W �> l( • - Z
6.Is(are)the wells) Permanent or oTemporary S a ofCcrtified Well Contractor Date
ev signing this forat,/hereliv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If lhir is a repair,fill out known well cmicn•uction it for•ntation and explain the ntlur•e q/the c•opv of this record has been provided to the well owner.
repair under#21 remarks section or on the back of Nris form.
23.Site diagram or additional well details:
S.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:
4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 471 (ft.)
For rrttt/tip/e weds/isl a//depths ifderent(eranrple-3@200'acid 3©!00') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.fiater level is above casing,use Static water level below top of casing._ (ft.)
1l'w Division of Water Resources,Information Processing Unit,
"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Iniection 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&Iniection Wells: In addition to sending the form to
�/ the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /t'I 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 2-22-201 G