GW1-2021-00556_Well Construction - GW1_20211222

f: �Prlrit Forlr
ELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1
I.Well Contractor Information:
HRISTOPHER WATCHER 14 WATER ZONES-
We I Contractor Name FROM TO DESCRIPTION
4 48A
ft. ft.
NC Well Contractor Certification Number
15.OUTER iCASING`(for,multi-casedswells pORL aIilicatile;
C MMINGS DEVELOPMENTS , INC FROM I TO DIAMETER T THICKNESS MATERIAL
Coi iliany Name +1 f1. ft. 6 in. PVC
1 16ANNER,C-ASING OR TUBING eothermal closed-loo 1..
2. ell Construction Permit#: 11>7-1 305 FROM TO DIAMETER THICKNESS MATERIAL
Lis all applicable well construction permits f.e.UIC,County,State,Variance.etc.) ft. ft. in.
3. ell Use(check well use): ft. ft. in.
W ter Supply Well: 17.'SCREEN
FROM TO DIAMETER 11 SLOTSIZE THICKNESS MATERAAI.
gricultu'al i Municipal/Public ft. ft. in.
Jeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.ustrial/Commercial Residential Water Supply(shared) 18.GROUT
atinn FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No -Water Supply Well: 0 ft- 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Inj ction Well:
quifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
quifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test [3Stonmwater Drainage fL ft.
xperimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING.G.LOG.(attacti additionel.sheets if necessary).
eothermal(Heating/Cooling Return) __ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ft. —7 W ft- r i )
4.Date Well(s)Completed: �,�2Z.�L1 Well ID# (eft. U
Sa.Well Location:
ft. ft.
ft. ft. it s _.
a e..
Facility/OwnerNamc Facility ID#(ifapplicable) ft. ft.
10 2.8 9Ae..L%.*.e d 1. ne dC--6h,,p -e Z?a 31 ft. ft.
Physical Address,City,and Zip ft. ft.
a.h! 1 qy 7 cZ SM 1 {C 1 21:REMARKS `
Cot my Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if i tell field,one lat/long is sufficient) �/ 22.�,,tificati.G O • N / / 6 7 7 W6. s(are)the well(s)oPermanent or Temporary aturc ofCcWcll Contractor Date
By sign' this form,1 herebv certify that the well(s)was(were)constructed in accordance
7. s this a repair to an existing well: []Yes or JMNo SA of
02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!0 it it a repair•,fill out known well construction information and explain the nature o e copy of this record has been provided to the well owner.
rep tir under#21 remarks section or or the back ofthis form. 23.Site diagram or additional well details:
8. or 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
coi struction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
duiled: 1 f Fb SUBMITTAL INSTRUCTIONS
9.�otal well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exannple-3@200'ands 22 n 1001 construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
lfw iter level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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
(i.e.auger,rotary,cable,direct pushy etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
F WATER SUPPLY WELLS ONLY: 1636 Mail Service Celiter,Raleigh,NC 27699-1636
13 .Yield(gpm) �`� Method of test: AIR ROTARY 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13 .Disinfection type: HTH Amount: � U 0•'i; completion of well construction to the county health department of the county
where constructed.
Foi GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016