GW1-2022-02940_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information: 7
CHRISTOPHER WATCHER 14.WATER ZONES
FROM TO DESCRI ION
Well Contractor Name ft ft� 'L 1/� �4448A (A U
ft. rt. 2 22 7
NC Well Contractor Certification Number 15.OUTER CASING(for 7u1N cased ells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+t ft. r „C' ft. 6 5/8 in. .188 G.STEEL
Company Name (t�
f� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' kz o� O 0 C I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ration FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 rt• PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stor'mwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION Icolor,hardness,soRtrock type, rain size,eh.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 ft. ,'dls ft. '
11
4.Date Well(s)Completed:Q2-2.7 Well ID# <1 tt. gib ft.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft. ft.
3000
rt. rt.
Physical Address,City,and Zip _
Or os�'&` q 7 -35azklo
L21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1d1 1 Q we
(if wellfield,one latAong is sufvicient) 22.Certifica
6.Is(are)the well(s)J§Permanent or Temporary amrc ofCcrtified Well Contractor Date
By signing this farm,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ®No 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 gf1he copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back 9 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: AA SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 7 10 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'annd 2@l00') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
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 ysJZ 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 2-22-20I6