GW1-2022-02838_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 DESCRIPTION
ft. 1 1 0
4448A
ft. ft.
NC Well Contractor Certification Number i
15.OUTER CASING(tor multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 5/8 in. .188 G.STEEL
Company Name
1. �, 16.INNER CASING OR TUBING(geothermal closed-loop)
'�
2.Well Construction Permit#: y l I-7 I q_t\)Z I FROM TO DIAMETER THICKNESS MATERIAL
Litt all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public it. ft in.'
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tr. ft. in.
Industrial/Commercial t3Residenfial Water Supply(shared)
IS.GROUT
_ 1ni ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft PORT.CEMENT POUR
I Monitoring DRecovety
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [I Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION tcolor,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
ft. 3 fL
,—�_ F
4.Date Well(s)Completed: Well ID# •7 ft. 1210 ft. I-
Sa.Well Location:
ft. ft.
a n Adams ?0 6e s e. ft.
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft.o 8 202Z
/ 6i 2721?
7 11 C'treen�.l r) c4 � r . 1✓`'1
Physical Address,City,and Zip
ft. ft.
1�1y�t7✓LLe— 8 9 14 o s C} 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long issufficient) 22.Certify 3
, .5z N IT' Z4• S3B t W Z-0-Zz
6.Is(are)the well(s)oPermanent or Temporary at, of Ccnificd Well Contractor Date
By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction infornralion and explain the nature ofthe copy gjthis 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: VA SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �9 V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 617 (ft.) Division of Water Resources,information Processing Unit,
Ifwater level is above casing,use"+" 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
ROTARY above, also submit one copy of thisi 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&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: A 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