GW1-2022-05939_Well Construction - GW1_20220627

i
SELL CONSTRUCTION RECOIL® Ow 1 Prinf Form=
77
1.well Contractor Information: For Internal Use Only: i
CHRISTOPHER WATCHER
Well Contractor Namo 19.iYATER•ZONFS
FROM ft.
DESCRIPTION
4448A fr. fr.
NC Wcll Connector Ccrtifi-Mle.Number ft. ft.
CUMMINGS DEVELOPMENTS, INC `16 AD RICASiNG fo"rmfildi.ed W11sj`OR�LiNER'ifa-tieable
Camp Name �'=,-•,FROM TO DIAML+TER THICKNESS
any +1 ft. 0 ft. MATERIAL
v a&/a I°• AN, 0,STEEL
2.Well C0110metion Permit#; aj 954 W ELM Z.2— ic16-.INNERi"CASING:OR`TUBING eoclseil=lSo
List all applicable wel!ronstrurlion peiwllts(i e.1 11t County Stale,Yarlauee,elc) FROM TO theriit;lr ti DIAMETER
R. THKiV iCES3 MATERIAL
3.Well Use(check well use): f t. IO
Water supply Well: ft. ft. ta.
Agricultural '171CREEIV'i _
g afMunic)pal/Public FROM TO DIAafR9ER SLOT SIZE Geothermal(Heating/Coolin Supply) ft fL in THICKNESS MATERIAL
Residential Water Supply(single)IndustriaUColnmercial
I/ri ion
Residential Water Supply(shared) ft.
'18..GRouT°
Non-Water Supply Well: oM To Y L MATCRrAL
Monitoring 0 ft. 20 ft EMPLACEMENT METHOD&AMOUNT
lf�ec ti e ft. ft.Recovery PORT.CEMENT POUR
on wll:
Aquifer Recharge 13Groundwater Romcdiation R'
Aquifer Storage and Recovery
E3SalinityBarrier ,19-BANDIGRAYEUPACK ifii` livable Aquifer Test
Experimental Technology tttlom To MATE _• _,
�St01111waterDrainage EL ft. RIAL EMPLACEMLNTMETHOD
Geothermal(Closed Loop) OSUbsidence Control FL
f4
Tracer
Geothermal ea tin '-20'DR➢LL➢NG' b tm Cooling Return) Other(ex lain under#21 Remarks) LOG attach addt0onalaheafs if:necess FROM TO DESCRIPTION ca/or,hordne rock salU -� '
® ft. ''-7 It. a ra/n size.etc.)
4.Date Well(s)Completed:IA--ZZ Well ID#
ft.
Sa.Well Location: P50 ft'
W
I_ ft. ft.
&. �
Facility/Owner Name ft.
Facility ID#(if-applicable) ft. ft
Physical Address,City,and Zip
to R ft. ft.
21d'REriIARI{S
County
Parcel ldentification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,ono lat/long is sufficient)
N- 0 29'e q0 / f 22.Certifcatio
w
6.Is(are)the well(s)OPermanent or 13Tempor2ry Signt(tturo of C• ' '3'ZL
I Contractor Date
7.is this a repair to an existing well: Yes or BY ag thin faun,J hereby cei7{/y Hutt the wells)was(wei eJ co Date
ht accordance
ePah is a repute;re ant known well consmrrcll m 1 oiftiallon a�N�ain d[e nalurn oflhe spy oltlds retard/ras been provided[o llte x ell otwter.
1h JSA NCAC 02C,0100 or 1SA NCAC 02C'0200 Nell Consinfcllon Slaudards and Hoot a
repair corder#2/remarks section a on the back ofHtisfonn.
23.
amor
l well details.
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You mey use rthe back of thisapage to Provide additional well site details o
construction,only 1 GW-1 is needed, Indicate TOTAL You may
drilled: NUMBER of wells construction details. You may also attach additional pages if necessary, r well
9.Total well depth below land surface: SUBMITTAL►.INSTRUCTIONS
For'multiple wells list oil depths ifdl Brent(exauple-3@200'and 2©100-) (f t") 24R. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following:
Jf water level it above casing ure`•+" (ff.)
Division of Water Resources,Information Processing Unit,1I.Borehole diameter: (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method: ROTARY 24b.kor.infection Wens: In addition to sending the form to the address in 24a
0.e.auger,rotary,cable,direct push,etc.) above,also submit one copy of this fonts within 30 days of completion of well
K construction to the following:
FOR WATER SUPPLY 4k1ELL5 ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) - 1636 Mail Service Center,Raleigh,NC 276994636
Method of test: AIR ROTARY 24c.For Water SuDD[y&Infection °lPlls: In addition to sending the formto
13b.Disinfection type: HTH 'Amount: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
Form GW-1
where constructed.
� •
North Catalina Department ofEnvironmental Quality-Division of Water Resources