GW1-2022-02929_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD GW-1 Print Form
For Internal Use Only:
t ,A.^Well Contractor information:
CHRISTOPHER WATCHER
Well Contractor Name 14•WATER ZONES
4448A FROM TO DESCRIP7ION
fL /
NC Well Contractor Conification Number ft. I `O
e. cj 2
15.OUTERCASING(formulti-cased wells OR INER Ifa livable
CUMMINGS DEVELOPMENTS , INC
FROM TU DIAMETER THICKNESS MATERIAL
Company Name +t ft.
ft. 6 518 in.
188 G.STEEL
2.Well Construction Permit#• �1 — Ol S 16.INNER CASING OR TUBING eothermal closed_loo
LislallapplicablPrue��catstnrrtianpeirnitc(i.,_,Coaatv.SlalP.iiulunre.elc.) FROM TO DIAMETER
THICKNESS MATERIAL
ft. t1• in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well:
Agticultutal 17.SCREEN
QMunicipal/Public FROM TO DIAMIs"I'ER sL0TS17,E 'THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) PfResidential Water supply
(single)
sin le) tr ft. In.
Industrial/commercial g fr. ft.Residential Water Supply(shared) in.
Irri,ation 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL
EMPLACEMENT Recovery METHOD&.!`_MOUNT
Monitoring 0 It. 20 ft PORT,CEMENT POUR
Injection Well:
rt. rt.
Aquifer Recharge E36roundwater Remediation ft.
ft.
Aquifer Storage and Recovery Osalinity Barrier 19•SAND/GRAVEL PACK(if a livable)
Aquifer Teat FROM MA
Q Stonn ft
water Drainage • EMPLACEMENT METHOD
Experimental Technology TO ft. TERIAL
QSubsidence Control —
Geothermal(Closed Loop) ft tt.
�Tt'acer 20.DRILLING LOG(attach additi Coolin R onal aheeta
Geothermal(Hearin Return) Other(explain under#21 Remarks)
FROM To it aecessa
DESCRIPTION(color,hardness,soil rock e, rain sbx,etc.)
4.Date Well(s)Completed:(2'22-2 1 Well ID#
t It.
t f t
5�We11 Loca' n:
�n_cr ...
�- ft.
Facilit tt'
Facility ID#(ifapplicable) fL ft.
�-�.��� C',he-o.�.t �-� I( iL Physical Address,City,and Zip ft B 2
Ct , t't• ir.
l•/ C] 21•REMARKS -- M
Copnty
Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one iat/rong is sufficient)
N / l 03.�(p b t 100,
22.Certifrcall
W
6.Ware)the wells)fDPermanent or oTernporary Signal ertificd Well
Contractor Date
7.iS this a repair to an existing well: QYes or EgNo By•signing 1hiv fot•m,/herebv ceriffs•that the well(.,•/was(were)consu'acled iu accordance
rePaI is a repair,fell out known ttrc•!I coawt•uction lnforutauon and explain the nauere afthe n'tpv n11/tNCACo as hrea or ISA prnv Ac dCo CeU tl(0o200 Well Consh ueliat Standards and Ilrn1 a
repah under#21 remarks section a•on the back oJ'this fam. co
8.For Geoprobe/DPT or Closed-Lou 23•Site diagram or additional well details:
construction,only I GW_ P Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
Y 1 is needed. Indicate TOTAL NUM drilled: BER of wells construction details. You may also attach additional pages if necessary.
For n9.Total well depth below land surface: yy� SUBMITTAL INSTRUCTIO VS
taltip/P wrll.0 list all depths lfd PrPIll
/pn,) 24a. For All Wella: Submit this form within 30 days of completion of well
10.Static water level below top of casing: / construction to the following:
11"vater level is above casing,11, '+'• J (ft.)
(in.) Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method:
ROTARY 24b.For lniec_ n Weps: in addition to sending the form to the address in 24a
`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,
13a.Yield(gPn) Method of test: AIR ROTARY/,� 1636 Mail Service Center,Raleigh,NC 27699-1636
24c. For Water 136.Disinfection type; HTH the addresses) abboovDly&Infection Wells: In addition to sending the form to
Amountve, also submit one copy of this form within 30 days of
yyv completion of well construction to the county health department of the county
Fornt GW-1 where constructed.
North Carolina Deparintcut of L•nvironntental Quality_Division of Water Resources
Revised 2-23-2U1 is