GW1-2022-05932_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: i. ;Print Form
1.Well Contractor Information:
CHRISTOPHER WATCHER
;A4.JVATER.ZONES;_
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft. E
NC Well Contractor Certification Number ft. ft. OF
15i•OUTER;CASiNG;.(fbr multi-cased&wells),OWL1NERq if a 'livable,CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. / ft- 6 518 in. .188 G.STEEL
•,'r� 11 L, �nj ` ,�/ �� 16.JN,EWCASING:0R'oTUBIN6, cothcrmahclased''-too);
2.Well Construction Permit#: �1 Ol W l:L 1 v Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,Comity,State,Irariance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: .17.,SCREEN:- .'_.: ._ - - ----
:]Agricultural oMunicipaUPublic ft.FROM TO DIAM1lETER SLOTSIZE THICKNESS MATERIAL
ft. in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single)
ft.
Industrial/Commercial Residential Water Supply(shared) G-
Itt :
l atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery19:;SAND/GK(ilia "licalile)
Salinity Barrier RAVEL.EAC
FROM TO MATERIAL EMPLACEMENT METHOD
Test E3Stommwater Drainage EL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 10:DRILLING, li additional sh'is if necessia.j;
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
, "L 27
ft.
4.Date Well(s)Completed: —Iq' uWell ID# 7 "' ; 1, ft. a CA
(J <
5a. /Well Location: ` n ft. ft.
ft. ft.
Facility/Owner Narn Facility ID#(if applicable) ft. ft.
0'199 C 5 t?Q V \r 1 tv'�if�a rt. rt. r r-, - d
Physical Address,City,and Zip l �j I� ft. ft. �k -
CO— lJ Q `g Z1'.:REXARKS,-, - -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: {ftivi ij a.,D
(if well field,one latnong is sufficient)
3�Q ` 1 1 7 22.Certifica'
N
6.Is are the wells Is(are) OPermanent or Temporary ignaturo cfttficd Well Contractor Date
signing this forin,I herebv certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iYell Constrnrction Standards and that a
Ifthis is a repair,fill out lenotm well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this fora.
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:
54 D SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 d (ft.)
For nit wells list all depths ifdii ferent(example-3@200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
Ifwater level is above erasing,:use'+" (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
ii.Borehole diameter: 6 (in.)
24b.For inieetion 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 WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Injection Wells: In addition to sending the form to
�HTH the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: ? d Z. completion of well constnuction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnviromnental Quality-Division of Watcr Resources
Revised 2 22-2016