GW1-2022-06264_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD (GW 1 Pr, Fol- y
2 For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER ;14wArElzoNEs
Well Contractor Name FROM TO DESCRIPTION
4448A `$Lo ft. b$ ft. (D 0""1
NC Well Contractor Certification Number f1 ft.
15 O,UTERLC*ASiNG<for muttrcesediivellsiOR L1NERi iI-a- `Iiealile .;.
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ^^ +1 ft. fL 6 5/8 In. .188 G.STEEL
2.Well Construction Permit#: �G^r�l 1 a /(� 16.;INNER'GASINGOR TUBING 'eornermal elosed5loo
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perm is C.e.UIC,County,State,_etc) ft ft. in.
3.Well Use(check well use): ft. ft. in.
r
ply Well: !'3.7CSCREEN"pl TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
al(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Commercial Residential Water Supply(shared)IrriIrrigation
ROi3T_ _FROM TOMATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 0 ft- 20 ft. PORT.CEMENT POURg Recovery ft. ft.
Injection Well:
Aquifer Recharge 13Groundwatcr Remediation ft. ft.
Aquifer Storage and Recovery49':SAND/GRA1VEL'PACK,if a"'licatile't
Salinity Barrier FROM TO MATERIAL EMPLACEMENT DiETHOD
Aquifer Test �Storntwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. tI.
Geothermal(Closed Loop) Tracer 20:'DRILL''iNGI OG atfacli:additiorialSheets if.oecessa ;',:'
Geothermal(Heating/Cooling Return) rjbther(explain under#21 Remarks) F OM TO DESCRIPTION(color,hardness,so Wrack e, min size,etc.)
rt. 41 ft. J r
_?_Z2 d i l
4.Date Well(s)Completed: Well ID# [.i!F ft. TO ft. 61
5a.a.'Well
(Location: �1 ft. ft. _ _
It(�n 1 1C1 S`n l DAII (��L LC ft. ft. 4.�. ..,.s r .r %,—V
Facility/Owner Name FacillityID#(if/alppl1U,C_liicaable)) ft• ft. 2022
I D 3 l P 0,01j1�� [�1f.A..r l-1 V rL 11.
Physical Address,City,andygl 1114Ci
21.'REIVIARIf5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient)
22.Certification.
6.Is(are)the well(s)oPermanent or oTemporary Si ire ofCcrtif ell Contractor Date
By si i dos form,I hereby certify that the svell(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Yes or JMNo pill,15A NCAC 02C.0100 or 15A NCAC 03C.0200 Well Construction Standauds and that e
Phis is a repair,fill out known well constriction information and explain the nature of the copy of this record has been provided to the well owner.repair under#21 remarks section or on the back of Unis form.
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: ou (ft.)
For nmltiple wells list all depths ifdifferent(kran,ple-3 a 200'and 2 a 100') 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 w _ater level is above casing,ruse '+,, � (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 ELLS 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&Iniection Wells: In addition to sending the form to
13b.Disinfection type: HTH nn the address(es) above, also submit one copy of this form within 30 days of
Amount: ad? 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