GW1-2022-05938_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD(GW 1) I Frint,Forrn
For InterTlal Use Only: `
1.Well Contractor Information:
CHRISTOPHER WATCHER
14c.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft ft. �2
NC Well Contractor Certification Number ft ft. 4
15;OUTER CASING.(for multi=cased wells)OR LINERt ifa '11 A e).
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +t ft. ft 6 5/8 ru• 188 G.STEEL
2.Well Construction Permit#: �l��a (Ll N 2 i :d6.INNERtCASING;ORIT_UBING; `eothermalAosed-loo ),_
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consn•etction petaats(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
FAal
�MunicipaUPublic FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
ating/Cooling Supply) lWesidential Water Supply(single)
ft. ft.mercial Residential Water Supply(shared)
I&GROUT. -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft
PORT.CEMENT POUR
Monitoring DRecovery
Injection Well: ft
ft.
Aquifer Recharge Groundwater Rcmcdiation ft ft.
Aquifer Storage and Recovery Salinity Barrier 19:"SAND/GRAVEL PACK(if a` H ble).
Aquifer Test �Stonn FROM TO water Drainage ft. ft. MATERIAL EMPLACEMENT METHOD
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer -20.DRILLING LOG additionalsNeets:if decessa"r., .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(eolor,hardness,sawrneB e, rain sbx,etc.)
ft. ft, i
4.Date Well(s)Completed: Well ID# fr. Flo ft.
Saa..,W_Well Location`:
c�SIN �J � h1� �5 ft. ft. ,'-�
' e Q
lFa11c11ility/Owned dame Facility ID#(if applicable) ft. ft.
49 5 o e r2 1Y, . �AY�IA l� '�a ft. ft. /r
Physical Address,City,and Zip ft.
8S7i ft. �- ;n Ur�;i
(\C� ' G l/' !J 21..REMARKS r.r tt. ,apt
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong i�sufficient)
3
22.Certif 'on,N�a3a-320 t W _
6.Is(are)the well(s)EC Permanent or oTemporary guatruc of Certif ell Contractor Date
By sigma, s form,I hereby certify that the tvell(v)was(were)consn tiled in accordance
7.Is this a repair to an existing well: Oyes or MNo with NCAC 02C.0100 a•15A NCAC 02C.0200 iVell Construction Standards and that a
/'this is a repair,fill out known well construction hirornnation and erplain the nature d opy of this reco d has peen 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (/ (ft.)
For multiple HIP&list all depths ifdii ferent(example-3Q200'and 2Q/00') 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:
(fivater level is above casing,itse"+" (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
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 WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
`7 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit olie copy of this form within 30 days of
13b.Disinfection type: HTH Amount: gzaz completion of well construction to the'county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources
Revised 2-22-201 G