GW1-2022-02846_Well Construction - GW1_20220228

Print�For
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name
FROM 'to DESCRIPTION
4448A
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased',wells)AR LINER ifa licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. I ft. 6 5/8 I in. .188 G.STEEL
Company Name 9 5
)l q 1 \W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: C 1 \ E LN Z I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIA_11L
Agricultural 13Municipal/Public ft. fr. in.'
Geothermal(Heating/Cooling Supply) 131tesidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18.GROUT
_ lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 it. PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test � ft. ft.
q [3Stomiwater Drainage
Experimental Technoldg'y Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional'sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc./
Geothermal(Heating/Cooling Return) __ Other(explain under#21 Remarks) % -
i► 1
4.Date Well(s)Completed:1~ Z5-2 2 well 1D#
5/a..Well Location: 30 tt. ✓3 ft. A�� 'm .1 _n_A
" �s
ft. 2,0 ft.
Facility/Owner Name
t- Facility ID#(if applicable) ft. ft. F Z n
U 5 Grl0.t� Far" -TTr 1 ft. ft.
Physical Address,City,and Zip-) ft. ft.
VA t-�kY1c e- g � 1 1� Y n 21.REMARKS
County Parcel Identification No.(PIN)
VPW-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufyfcient) 22.Certification-
6.Is(are)the well(s) i Permanent or Temporary zy"
c of Ccrt' Contractor Date
g this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No r 15A NCAC 02C.0100 or 15A NCAG02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of e 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: 40 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 welts list all depths ijdiJferent(example-3@200'and
2@100') construction to the following:
10.Static water level below top of casing: l Vl (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 Iniection 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 f
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 Zone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /�O�. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016