GW1-2022-05947_Well Construction - GW1_20220627

uh ,Font.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER ia:=wATERzoNEs -
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft /
,s^
NC Well Contractor Certification Number ft. ft. g4�J �!
15:;OUTEM 7 ASING'(fae,inultl Mif9 d=wells OIt LINER'iffa"Rca$le
CUMMINGS DEVELOPMENTS , INC FROM TU DIAMETER THICKNESS I MATERIAL
Company Name +1 [t. ' f4 6618 in. .188 G.STEEL
_16:;INNER;CASINGVR'TUBING eotifecmal'closedaoo
2.Well Construction Permit#: --)aRl0 toe -•N 22 FROM TU DIAMETER THICKNESS MATERIAL
List all applicable well construction pet7mits(i.e.UIC,Cotatty,Slate,variance,etc) ft [t. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17i SCREEN[ _,.. ..
AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E31tesidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared)
ft. ft. in.
P Irrigation ation I "',aROUTi` ',;. - - _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: a ft. 40 ft.
PORT.CEMENT POUR
..Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge [30roundwater Rcmcdiation ft. ft.
Aquifer Storage and Recovery ;19 SAND/GRpYEL'+P.ACK'rfi'a' 'llcable�; -
13SallIllw terDr FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test �Stotnrwater Drainage fL [t.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) MTracer
`.+20iiDRItitiING1OG.attach•ad`ditionalsheefsdf,necessa.')'.'�:��• � __ -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To
_; DESCRIPTION(color,hardness,saittraek e, rate size,ere,)
4.Date Well(s)Completed:-6 l 2 —?_2 Well ID# ft.ft. '— ft. 'R,
Saa..Well Location:
,,t -,•& �5�.e e cw
Facility/Owner Name
Facility ID#(if applicable) 1't• ft.
PF c)
113 l 1.k�►1 It (lcl�-{�j n n. ft. JUN ,,
Physical Address,City,and Zip ft. ft. iv..;, It r
cae- (p _21:iREMARKS:._c tt•a
n a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlltiirg is sufficient) r
36 b1 4 7it 7 / 1 22.Certificati
79 � r� �
6.Is are the well s Is(are) O ..,Permanent or Si�^' �Teroporary uroofCcrt' c11Contmctor Date
7.Is this a repair to an existing well: [3Yes or JRNo Y sign' Is form,I herebv cerl!fy that the well(s)was(were)constrrtcled in accordance
a
SA NCAC 01C.0100 JSA NCAC 02C..0100 Well Consh7rctlah Standards and that a
Iflhls is a repair,fill orrl known well coil
struction information and explain the nature of the copy ofthis retard has been provided to the well owner.repair under#11 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: _
zoo SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!f derenl(e raople-3@200'and 1 eQ/00')
construction to the following:
10.Static water level below top of casing:
If ivater level is above casing,rise'+' / (ft•) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
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.) constiuetion to the following:
EWATERPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: AIR ROTARY 24c.For Water Sumoly&Infection Wells: In addition to sending the form to
type: Amount:HTH the address(es) above, also submit one copy of this form within 30 days of
��®2. 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