GW1-2022-02840_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW 11 ly: Print Form
For Internal Use On
I.Well Contractor Information:
CHRISTOPHER WATCHER
14 WATER ZONES_
Well Contractor Na mc FROM TO DESC IPTION
4448A ft. ft. 10 q 11
NC Well Contractor Certification Number ff ft. q �„1 ei—
lS:OUTER;CASING(for mtiI&ciu*&ivells OR LINERJif a 6cable)CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft
C,� +1 ft. . 6 5/a in. 188 G.STEEL
2.Well Construction Permit#:_ W 1 p1 L�� I 16. NNER CASING:OR'TUBING' 'eothermal dosed=too"'.
FROM TO DIAMETER THICKNESS MATERIAL
List all applicahle well ronstruction permits(i.e.UIC,County,State.Variwwe,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN: _
Agricultural Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT.
Non-Water h l FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: o ft- yo ft
PORT.CEMENT POUR
_!Monitoring Recovery R
Injection Well: ft.
Aquifer Recharge nGroundwater Remcdiation ft• ft.
Aquifer Storage and Recovery19i SAND/GRAVEL'PACK,(if a `licable '
Sahnity Barrier FROM TO MATERIAL EMPLACEMENT\fETHUD
Aquifer Test oStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) E)Tracer 20.DRILLING LOG aftachsaddition5l,sheets.ifnecessar.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DF,SCRIP'1'ION Icoloq kardness,soiVrock e, rein six,etc.)
ft. Q ft. d
4.Date Well(s)Completed: 2 well 1D# q f ft. ft. C7 LI
5a.Well 1Lottcatioonn: ft. ft.
—CE30n -t ft. ft.
Facility/OwncrName Facility ID#(ifapplicable) ft. ft.
_C9 Q to I S �c 2 9 S n rCt.hnrv� o27a,55an
rt. P
Physical Address,City,and Zip ( G r ft, ft.
1�1QIV�(�1�N C_P d 8 6 0� a7 c� q 1 21.:RENL4,RKS ,.
County ti
(, Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latllong is sufficient) 22.Certificatio .
6.Is(are)the well(s)oPermanent or oTemporary S' anuc d ell Contractor Date
signing this foriu,1 herebv certify lhal the ivell(s) was(were)constructed in accordance
7.is this a repair to an existing well: Oyes or MNo ivirh 15A NCAC 02C.0100 or iSA NCAC 02C.0200 TiVell Construction Standards and that a
(this is a repair,fill out known well contraction information and explain the nature ofthe c'oPY gfthis record has been provided to the hell owner.
repair under#21 remarks section or on the back q/'ilris 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: 2 J (ft.)
For multiple wells list all depths ifdii ferent(exmrrple-3@200'and 2 100') 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:
Ifwater•level is above casing,use ,+,, (ft.) Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 (in.)
1617 Mail Service Center,Raleigh,NC 27699-1617
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,eta) 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 lWells: In addition to sending the form to
23HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ®Z completion of well construction to & county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 2_ 2_
Revised_2_2016