GW1-2022-06273_Well Construction - GW1_20220628

° rint Farris .
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER =:,14<WATERZONES -
Well Contractor Name FROM TO DESCRIPTION
4448A
ft. ft. eL CP
`
ft. ft.
NC.Well Contractor Certification Number C lS.COUTERCASING:(for;multi cased wells,OR'L'INERa ifta"Q¢atile.
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6 5/8 in. 1 BB G.STEEL
' •�^ 16ANNER,CASING:ORTUBING_ eothermaLdosedaoo '
2.Well Construction Permit#:S _�- — QND-7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conslrarlion pel its(I.e.UIC,Conrrty,State.Yarianre,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Su r14iISCREEM :..' , ......
PPIy Well:
.Agricultural h1tOM TO DIAMETER SLOTSI%E yTHICKNh'S MATERIAL
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. PORT.CEMENT POUR
:.)Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Rcmcdiation ft. ft.
Aquifer Storage and Recovery49,SANDZGRAYEL�PA- :if;a-'licatile
Salinity Barrier FROM TO MATERIAL EMPLACEMENT alETHUD
Aquifer Test [3Stonnwater Drainage ft. ft
Experimental Technology oSubsidence Control fa ft.
Geothermal(Closed Loop) Tracer �20lfDRILLING LOG'attachiaddGionahsheetiiiifeecessa );__
Geothermal(Heating/Cooling Return) r.10ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soturack type.gmin sire,etc.)
® �/
ft. fL &e)
4.Date Well(s)Completed: _ Well ID# q i ft. / ft G
5a.Well Location: 2a '7 ft. (OU FF
ft. -. ':;�»..
Ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft• ft.
�. 1y►rl
ft. In:c; w cis . fo ,,w� g Uni7
Physical Address,City,and Zip ft. ft. '•
21 REMARK$' i
County Parcel ldcntification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laatil /ong isIufficient) � / 22.Certiffeatio
35 Q 52-b% N /90 DN[10 S q` W
6.Is are the wells �ZZ
Is(are) ()Permanent or Temporary Si turo of rficd Well Contractor Date
going this foray,I herebv certify Thal the well(s)was(were)constructed br accordance
7.Is this a repair to an existing well: E3Yes or JRNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Construction Standards and that a
Ph&Ls a repair fill oul known well carsh•nction information and explain the nature oftre copy ofthis record has beet provided to the well owner.
repair under#21 remarks seclion or on the back of thisforal.
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.
dolled:
�llN9.Total well depth below land surface: (z�/ SUBMITTAL INSTRUCTIONS(ft.)
Far•multiple wells list all depths if different(i:rarnple-3@200'and 2@!00') 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:_ d ft.)
If water level is above casing,use`•+,, ( Division of Water Resources,Information Processing Unit,
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(gpm) Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
136.Disinfection type:
HTH )��� the address(es) above, also submit one copy of this form within 30 days of
Amount: / 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