GW1-2022-05942_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: I_ ;P-<rmt'Fol m'
1.Well Contractor Information:
CHRISTOPHER WATCHER
Well Contractor Name FROM TO DESCRIPTION
4448A fc. ft. 4 +,
ft. ft.
NC Well Contractor Certification Number
15:QUTERiCASiNG(for mulh ciise$nw6 V11' ERrt'ifia"'livable CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +t ft. 3 fL 6 5/8 in. .188 G.STEEL
+. ) i `•I'&ANNER,CASING_OR,TUBING:.`-'eothermal closed'loo') ___'-- •_
2.Well Construction Permit#: 'Of-1 11�J�L��` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction per•rnits(I.e.UIC.Coanty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17:;SCREEN;
'Agr'1CUltUral FROM TO DIAM1tETER SLOTSILE, -THICKNESS M1IATERIAL�
Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT _
Near--Water Supply Well: 0 ft. 40 ft. PORT.CEMENT POUR
Monitoring JDRecovety ft. ft.
Injection Well:
Aquifer Recharge []Groundwater Remediation ft. ft.
19:SAND/GRAVEL PACK;(i$a 'livable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT M1iETHUD
LGeothermal
ifer Test 13Stormwater Drainage ft. ft.
erimental Technology Subsidence Control
thermal(Closed Loop) OTracer ,20.:DRILLING1tiOG attach:addGionAsheets:if necessa.)"(Heating/Cooling Return) _,Other(explain under#21 Remarks) FROM o To DFSCRIPTION(color,hardness,soilfrock e, rain size,etc.)
ft. ft.
4.Date Well(s)Completed: 23`Z-�-well ID# Z ft. oak
5a.Well Location: ft. ft.
(('N Nc�i���o� ft. ft.
Facility/Owner Name J Facility]D#(if applicable)
p (�A ft• ft
Physical Address,City,and Zip ^ 4 ft. ft.
I-- a n/{C:"t��(ra d `1��9 8,)� 21:REMARKS _,- --
County Parcel Identification No.(PIN) J1°: eSQG'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
('if well field,one lat/long is sufficient)
1 1 22.Certific n:
3s�5 3�� N 19'' �6 r ��� W
6.Is(are)the well(s)gPer'manent or Temporary ignaturc c ' c Well Contractor Date ✓��
signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JX No - with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consmrction Standards and that a
lfthiv is a repair,fill out krrovn well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or of the back of thisfortil.
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:
zoo SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For mrdliple wells list all depths ifdii different(e.Tanrple-3 a 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:If water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
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 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) 4 Method of test: AIR ROTARY 24c.For Water Sunvly&Iniection Wells: In addition to sending the form to
13b.Disinfection type: HTH
the address(es) above, also submit one copy of this form within 30 days of
Amount: 906$ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2 22-2016