GW1-2022-02836_Well Construction - GW1_20220228

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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 DESCRIPTIONft. ft. � �"� 2 I
4448A v
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. -- ft. 6 in. PVC
Company Name
/' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 31 toy 1,,,)I;ZN 19 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 1S.GROUT
_!Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f= 20 f= PORT.CEMENT POUR
_I Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessar )
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc.)
_ ( g/ g ) J Other(explain under#2l Remarks)
H. & ft. �ad
4.Date Well(s)Completed: Z1-Z-L Well ID# ft. 2yo ft.
5a.Well Location:
P' 1h4CIN elra1/e,,,!, ft. ft. rr
Facility/Owner Name Facility ID#(if applicable) tt. f=. Mt
Eg 2
1031 U S IYl 2} ICLJ s•?off- 510Z 0&"0 Z7 3` 1 tt. rt. Coln IJ4
Physical Address,City,and Zip - I
AaMCANLC- �74994I00S 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
350 SS.g33' N '?9° 30 •S8a' W ,/��✓ -Zl -zz
6.Is(are)the well(s)oPermanent or OTemporary S' tore of died Well Contractor Date
8 ning this form,1 herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis it a repair,fill out known well construction information and explain the nature of the copy of this 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'a(nndd 2@100') construction to the following:
10.Static water level below top of casing: I-I (ft.) Division of Water Resources,Information Processing Unit,
!!water 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 done copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ' �'Z- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016