GW1-2022-02899_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 DESCRIWI'ION
ft. ft. a
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a Iicable
CUMMINGS DEVELOPMENTS , INC FROM TU DIAMETER THICKNESS MATERIAL
+t ft. ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Z 8 S-4 11 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 I SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr. fr. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_' Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft' 20 ft PORT.CEMENT POUR
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge rliGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
!Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test [3StomtwaterDrainage
!Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIPTIO I[color,hardness,solurocl e, rain sire,etc.)
I / J ft. ot ft. .� J
4.Date Well(s)Completed: I Z 10`` ell ID#
55aa.{Well Location:
l Y�HS�GI►n �YAVI S ft. ft. RECFIVED
Facility/Owner Name Facility ID#(if applicable) ft• ft.
to�"D8 �i4,OW4 U L:.+11� 21 a9� rt. rt. _
Physical Address,City,and Zip ft. ft.
GV�k LA
FUR99701) 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.Certifica
3S" 5Y. 743 1 N 190 3YrSSo W �- 2G.u.
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Cc Well Contractor Date
ung Phis form, I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 12-0 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 ifdii ferent(erample-3@200'arrn--d 2@100') construction to the following:
10.Static water level below top of casing: 01� (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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:one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /Z.d'a- 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 I Revised 2-22-2016