GW1-2022-02843_Well Construction - GW1_20220228

' WELL CONSTRUCTION RECORD(GW 1) T PrintFolm
For Internal Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
14.WATER ZONES
Well Contractor Name FROM TO DE IP'1'!ON
4448A it ft. I
NC Well Contractor Certification Number f1• ft.
CUMMINGS DEVELOPMENTS , INC FROMUTER,GTOING(form D AME ERASlti-cosedivells OR�CKNESS a 15. Ii MATERIAL
Company Name +1 ft' Y_ ft• 6 5/8 in. 188 G.STEEL
*1$ lJ�"L1�21 16;INNER CASING,OR TUBING. eothermal;closed400 2.Well Construction Permit#: �14
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Nell contraction perallts(i.c VIC C011111y,State,I�al7all('e.C'(c.� ft. ft. in.
3.Well Use(check well use): ft• ft. in.
r
ply Well: 17.SCREEN.
ral FROM ToDIAMETER SLOTSI7.E THIKNESS MATERIAL
Municipal/Public ft. ft. In.
al(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in.
Commercial Residential Water Supply(shared)
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:Monitoring Recovery o ft. 20 ft.
PORT.CEMENT POUR
Injection Well: rt. rt.
Aquifcr Recharge oGroundwater Remediation ft. ft.
Aquifer Storage and Recovery DSalinity Barrier 19+.SAND/GRAVEL PACK if a liiiahle
MATERIAL
Aquifer Test DStonnwater Drainage FROM ft. TO ft. EMPLACEMENT METHOD
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING'LOG-(attach additional•sheets if necessain
Geothermal(Hearin Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soill-ek e, rain sbx,etc.)
Q 0 «. 2 2 ft'
4.Date Well(s)Completed: ' V ?-Z Well ID# 2 ZfL 2 1 0 ft•
5a.Well Location: ft. ft. I
ft. ft.
Facility/O Name Facility ID#(ifapplicable) ft. ft.
FE
0 A1 I Y-G x t (z rQ�M- rL «. eilAOupw
Physical Address,City,and © �•, `, ft. ft.
lb
C e_ O D 1 1 'e� r 11.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)
3 22.Certifica'
(� N / r O W /
6.Is(are)the well(s)oPermanent or Temporary ignat citified Wcll Contractor Date
7.Is this a repair to an existing well: 0-yes or MNo With 115AlNCAC 02C.0100 or ISAtNCAC 02Cify that the.0200)Well Construction Standards and wav(were)constructed in accordance
at a
#'This is a repair fill ont knolvn well con.Thrrction information and explain the nature ofthe coPv ofthis record has been prnv/ded to the Ke!/ow/1er.
repair under#21 remarks section a•on the back oJ'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: /L- (ft.)
For/multiple wells list all depths ifdiiferem jexan pre-3@200'and 2Ql00') 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: f* �.�C�Q,A
Ifivater level is above casing,use + ��'•r ^r (ft.) 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) 7Co AIR ROTARY
Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
HTH the address(es) above, also submit'one copy of this form within 30 das of
13b.Disinfection type: Amount: 2�c� 7 completion of well construction to the county health department of the county y
where constricted.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
i