GW1-2022-05948_Well Construction - GW1_20220627

'Pint Form"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER
4.,VA-TzRLZONE&:
Wall Contractor Name FROM TO I DESCRIPTION
4448A ft. ft.
ft. ft.
NC Well Contractor Certification Number
-kd EWCASM431116riffiii1tRais.15.JOUT
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS I MATERIAL
Company Name +1 ft. ft 6518 .188
G.STEEL
. 1 F&IN NER..CAOING(R,TUB
DIINAMGiEtTbEeRt ine. Ic .002.Well Construction Permitm D5`7 QEL0Z THICKNES
MATERIAL all applicable well constrilclionpenijv(.e.UIC.COIIIDState.Variance,Cie.) --3.Well Use(check well use): ft. ft. in.
Water Supply well: '17;'S.CREEN;'.,-. 77
FROM TO DIA51EIIIE SLOTSIyF -TH—ICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft.
Industrial/Commercial E]Residential Water Supply(shared)
Irrigation I&GROUT.
FROM TO MATERI
AL EMPLACEMENT METHOD&A4tOUNT
Non-Water Supply Well: 0 ff* 20 PORT.CEMENT POUR
Monitoring
Injection Well: Recovery a j
Aquifer Recharge [3Groundwater Remediation ft. ft.
�1 X SANDIGRAVEL-i PACK,72---7-—-_77. 1 77-—-
Aquifer Storage and Recovery 13Salinity Barrier Wa licab'10017--
FROM TU MATERIAL
Aquifer Test [3Stormwater Drainage ft. _KMKLACEM9,_NT METHOD
Experimental Technology oSubsidence Control ft. ft.
Geothermal
eothermal(Closed Loop) 13Tracer 20i�',DRILL 1
Geothermal
OG on i ee i ned ig
eothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 1 FROM ft. TO ft. DESCRIPTION(color, rainsize,etc.)
4.Date Well(s)Completed:Sr—I I 0-V Well ID# ft.
Sa.Well Location: ft• ft.
ft. ft. V
Facility/Owner Name Facility ID#(if applicable) —ft. _i t. k V
�Io2 7,202
ae55 Aafai;iiru cl, ft. it. 2
Physical Address,City,and Zip ft ft.
Praczcu .q Unii
�121-'-'.,REM RKS, 7 -7
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,One latlong is slificiant) 22.Certi .0
360 oz.LY60 N 0 994
6.Is are the well(s)OPermanent or [3Temporary Signatt c Well Contractor Date
S' jig thisforin,lherebv that the wefl(s)was(were) ractedin accordance
7.Is this a repair to an existing well: nYes oroNo with 15.4 XCAC 02C.0100 oh ISAcerfify NCAC 02C.0200 011 Constructicononst Standards and that a
Phis iv a repair,fill out known well construction Information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisforla.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 t_j (it.)
For 24a. For All Wells: Submit this form within 30 days of completion Por n'11110 ifle wells list all depths different('.rumple-3@200'and 2@100') cons on of well
itruction to the Following:
10.Static water level below top of casing: I
V'water level is above cashig,use',+,, (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,ere.) 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) Method of test: AIR ROTARY 24c.For Water Supply&Injection Well,: In addition to sending the form to
13b.Disinfection type: HTH Amourtt:�907_ 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016