GW1-2022-05941_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
CHRISTOPHER WATCHER �-]aaWATER ONES. -
_ Well Contractor Name FROM I TO DESCRIPTION
4448A
ft. ft.
ft. ft.
NC Well Contractor Certification Number
'15:'OUTER%CASING,(foi•�ieulh`caseil4twells)_URiLINER�"itsa`"ucatile _ '
CUMMINGS DEVELOPMENTS , INC FROM To DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6 5/8 in. .188 G.STEEL
16.rINNER EASING OB_TUBIPIGI"eo4hermandosed=too
2.Well Construction Permit#: it Lo Z Z FROM TO DIAMETER THICKNESS MATERIA List a!/applicable.well construction pe,sntLs ri.e.U1C,Catn,ty,Stale,Variance,etc) ft. R. in. L
3.Well Use(check well use): ft. ft. in.
Water Supply Well: `WSCREEN»:
Agricultural []Municipal/Public ft. ft.FROM 1'O DIAMETER in. SLOTSI7.E THICKNESS MATERIAL'y
Geothermal(Heating/Cooling Supply) tffResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial E311esidential Water Supply(shared)
78.,GROUT':.
Non-Waate ..
irrigation eFROM TO J MATERIAL EMPLACEMENT METHOD&AMOUNT
• r Supply Well: a ft. 20 ft
PORT.CEMENT POUR
MonitoringRecovery ft. tt.
Injection Well:
Aquifer Recharge Groundwater Rcmediation It. ft
49.iSAN DIG HAVE UTACK ifa""licatile '
Aquifer Storage and Recovery Salinity Barrier ,
FROM TO MATERIAL EMPLACE—ENT
D
Aquifer Test oStormwater Drainage & ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ^20:aDRILL'iNG'1L ;a s ee I 'nefessark
Geothermal(Heating(Cooling Return) _; Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solUraek e, ram size,etc.)
Q ft. fL 1
i
4.Date Well(s)Completed: )2.-2Z O
Well ID# ft. ZO ft.
5a.Well Location: ft. fL
M L I ),,l hi1m ft. It.
Facility/Owner Name Facility ID#(if applicable) ft• ft. r �• "'
Qfl Lo tea-i,�n ft. ft. J U N 2
Physical Address,City,and Zip o �- ft. ft.
�- Unh
� �f 2
County
Pared Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
12 ' a / 22.Certiticatio
° b l' !!,_N - /9 U W j
6. )the well Is are
( (s)Permanent orTemporaty Si two of Certified ontractor Date
By signing! ' ornr,1 herebv certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r3Yes or ISNo Slid, CAC 02C.0100 or 15A NCAC 02C.0200;Yell Cons#ruction Standards and that a
/f this is a repair;fill onn,lo,own well construction information and explain the nature opy of this record has been provided to the well ouster.
repair under#21 remarks section or on the back of thisform.
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:
i,,0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `L'- (ft-)
Fa multiple wells Ils►a/l depNts;fdi[ferent ti Sample-3 rt 200'and 2©100q 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: to
lfwater level is above casing,rise"+^ (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Iniection 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 rite 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&Iniection Wells: In addition to sending the form to
13b.Disinfection hp •e. 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
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016