GW1-2022-05950_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER - -
• •.;14:,tWATER`ZUNES_-�'�_ .r, .` --- -_ ____ _
Well Contractor Name PROM i TO DESCRIPTION
4448A ft. ft.
NC Well Contractor Certification Number ft. ft. C1
;15i'OUTER CASING.forimulh=cesedLiv"ells;OR;LINERf (a 6calile
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. Fi fL 6 518 In, .188 G.STEEL
2.Well Construction Permit#: 5a 8B WEL Q-2 OM TO DI
16 INNERy.CASING DIAMETER THICKNESS.eotheeiiialid
FRAM MATERIAL 'List all applicable well construction permits(i.e.UIC,Coan%Stale,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17a0CREE14 ;_ - -- _ -_
Agricultural FROM TO DIAMETER SLOTSI7.E THICKNESS' NINfERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
Industrial/Commercialft. ft. in.
Residential Water Supply(shared)
i,78aGRQUT;
If[i gation FROM TO MATERIAL EMPLACENT METHOD&AMOUNT Non-Water Supply Well: EM Monitoring a ft. 20 ft
PORT.CEMENT POUR
Recovery ft. ft.
Injection Well:
Aquifer Recharge 13Groundwater Remediation f t' ft
Aquifer Storage and Recovery Salinity Barrier 79:iSAND1GRAYEt P.ACK:(i"a"Iicalile)
FROM TO MATERIAL }, EMPLACEMENTrrfETHUD
Aquifer Test �Stomrwater Drainage fa ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20i DRIDI ING1OG attadi?addltionaGsheiftsi _iEirecessa )..�
Geothermal(Heating/Cooling Return) ;Other(explain under#21 FROM To DES IPTIon icalor,hardness,sole ck e.P Remarks) ft. ft. rate sl>R,etc.r
-
4.Date Well(s)Completed: ZZ Well ID#
5a.Well Location: ft. iL
To pact Kolarkn ft. fr. q �,m
IJ
Facility/Owner Name Facility 1D#(if applicable) n• &
TIRO Shalla'-> 'oCd Chug-y"M ft.
Physical Address,City,and Zip ft. ft.
- .. ..
885(
A-k3AVT-1M 0l `I3 b$9 21.REMARIfS:.,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlloltg is Sufficient)t / 22.Certific �
�G o 1 z�©
6.Is(are)the well(s)oPermanent or oTemporary Signature o cd well Contractor I I-2�
Date
7.Is this a repair to an existing well: []Yes or JRNo wi11,r115AnNCAC 02C.0100 o-ISArfy NCi1C 02C that the t0200 Mel/Co,st ruction Slandmds and accordance
a
!This Lr a repain fill oul known well c0ns8•uction information and explain the nalm a of the copy ofthis record has been provided to the ir'e//owner.
repair under#21 remarks section or on the back ofUds foal.
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:
9.Total well depth below land surface: ?�,670 SUBMITTAL INSTRUCTIONS(ft.)
For multiple wells list all depths ifdieren!%esan,ple-30200'and 2Qi o0') 24a. For All Wells: Submit this form within 30 days of completion of well
��Ifwater construction to the following:
10. water level below top of casing: (ft.) Division of Water'Resources,Information Processing Unit,
ter level is above casing irse'•+'•
1617 jilail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) .;'t
24b.For infection"Weiss: 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 cillowing:
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 SuoDly&Injection 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:ZO®g completion of well construction to the county health department of the county
where constricted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsouicrs;
Revised 2-22-2016