GW1-2022-02973_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD (GW 1) _ Print Form
For Internal Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
Well Contractor Name 14.WATER ZONES
4448A
FROM 't'O e. DESCRIPTION•
e. ' , d
NC Well Contractor Certification Number ft.
FROMUTER CASING(for multi-cased wells OR LINER ifs licable
CUMMINGS DEVELOPMENTS , INC
DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6 in.
PVC
2.Well Construction Permit#: WoZ - 033 16.INNER CASING OR TUBING eothermal closed-too
List all applicable well constructionl,rals(i.e.U/C'•C011nty.Stare,uarianc e,rtr.) FROM tL TO DIAMETER THICKNESS
MATERIAL
ft. in.
3.Well Use(check well use): ft.
ft. in.
Water Supply Well; 17.SCREEN
Agricultural Municipal/Public FROM r0 DIAMETER SLOTSIZE 'THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) ft• tt. in.
g PP Y) Residential Water Supply(single)
Industlial/Comnercial ft. rt. in,
Residential Water Supply(shared)
Irri•ation 18.GROUT
Non-Water Supply Well FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft' 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge �Cnoundwater Renicdiation ft. ft.
Aquifer Storage and Recovery QSalinity Barrier 19•SAND/GRAVEL PACK if a licable)
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
QStonnwater Drainage f[. ft.
Experimental Technology QSubsidence Control —
e. rt.
Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 20.DRILLING LOG(attach additional sheets if necessa )
FROM TO DESCRIPTION
(color,hardness,soil/rock type, rain sbr,etc.)
ft. � [' ft. ;�1 4.Date Well(s)Completed: Z _ZZ Well ID# ft.
Yet' r,Q t
Sa.Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Q�ia� 0) v- Ir, �r�tin 1 a��o5 (t.
LJ
Physical Address,City,and Zip —
ft• ft.
()raro� 1893a l0 3l00$
21.REMARKS
County V Pared Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0
(if well field,one lat/long is sufficient)
340 bz.,g"(G ' N ''1(30 O/r f�eY/ 22.Certif
I J D W
6.Is(arc)the well(s) permanent or Temporary stoic of Certified Wd ontractor Date
7.Is this a repair to an existing well: Yes or @No By signing this form, /herr•bv cerlijy that the wells) was(were)c•on trucied in accordance
lf7his is a repair,fill oul known well col'aruc•tion inOrnmlion and erplain the nature of the co n t Rv of thNCA is record has beet provided to!e"'ell 0200 Well Construction Standards and!hal a
repair under#21 remarks section or on the back al this faun.
23.Site diagram or additional well details:
S.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 ifnecessary.
drilled:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
Far uudliple wells list all depths)j dierent(examp @ 00'le-3 c 2and_Q/00') lff) 24a. For All Wells: Submit this foam within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 011"
j(warei level is ahore casing,rice"+" (ft•) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
(in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b. For Injection 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 WA:(gpm)
SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
l3a.Yiel Method ot'test: AIR ROTARY24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disj type; HTH JL the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department orEnvironntcnlal Quality-Division of Water Resources
Revised 2-22-2016