GW1-2022-05943_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER ;:14:WAmERzoldEs,_
Wall Contractor Name FROM TO DISC T10N
4448A ft. ft. 21 re,
ft. ft
NC Well Contractor Certification Number
;15:UUTERCASING(For<rttulh.ea`seiltave0s)QItLINER?if{a 'li¢alile
CUMMINGS DEVELOPMENTS, INC FROM To DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6518 In. 188 G.STEEL
'' 11 INNER CASING'.URTUBING eo"thermal-:closed=too`2.Well Construction Permit#: "1�� 3 EL(� Z I FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well cahstruction pewmLs(I.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.:SCREEN:
Agricultural FROM TO DIMIF:TEn SLOT Sn E THICKNESS MATERIAL
E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
IndustriaYCommercial ft. ft. in.
Residential Water Supply(shared) -
18::GRbUT. _.
RI at10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft.
PORT.CEMENT POUR
MonitoringRecovety ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft
Aquifer Storage and Recove {�, 19„SAND/GRdYEL PACK.if.
—'licable)C IY p�SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test J3StOmlwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer ZOE,DRILtiING'LOG attacli:addliloiial.,shiits,ifnecessa
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) O TO DESCRIPTION(color,hardness,en rack e, reln size,etc.)
ft. � ft.
4.Date Wells)Completed: - Z7i Well ID# ft. h ft
5a.Well Location: ft, ft -
$vale lD ti D ft. ft 9 7 .202
Facility/OwncrNamc Facility ID#(if applicable) ft• ft
N HI 111 Z lUrl' rt. ft lni;,;;,�r«��
Physical Address,City,and Zip
ft ft.
�1-• :• q
"ems N C� —� 1 O LI lG�LI O
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient)
22.Certifica'
W
6.Is(are)the well(s)OPermanent or Temporary hgnattlro of ell Contractor . 54 'ZZ
Date
7.Is this a repair to an existing well: Yes or �No signing this fornh,I hereby certify that the well(a)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 lVell Constauctiar Standards and that a
!#"ibis is a repair,fill out known well catstruction information and explain the nature of the copy ofthis retard has been provided to the well owner.
repair under#21 remarks section or on the back of thisforal.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Y page p `'"
You may use the back of this a e 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:
320
® SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For Multiple wells list all depths if different(example-3 r@e a 200' ad 2 100') 24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following:
1 water level is above casin0.Static water level below top of casing:_ (ft.) Division of Water Resources,Information Processing Unit,
f l,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection 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{gpin) Method of test: AIR ROTARY 24c.For Water Suooly&Infection Wells: In addition to sending the form to
136.Disinfection type: HTH Amount: the addresses) above, also submit one copy of this form within 30 days of
324 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