GW1-2022-06427_Well Construction - GW1_20220511

Prdt Form
WALL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER r4kWATER$UNEs' = --
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft. )25
ft. ft.
NC Well Contractor Certification Number
CUMMINGS DEVELOPMENTS , INC FROM CTOING fdrmDIAM TERe�'OR is NEss a ItrvinITERIA>L r
Company Name ft. ft 6 5/8 In .188 G.STEEL
i'46.:INNER,CASING:OR�TUBING'1�eoth'ermal-closed@loo`� .�-
2.Well Construction Permit#: F)Oo FROM TU DIAMETER THICKNESS MATERIAL
List all applicable well construction peurnits(11.e.VIC.County,State,Irariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:,SCREENi
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
g [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 4akesidential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation 18:'GROUT �.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it PORT.CEMENT POUR
Monitoring [311ecovery ft. fL
Injection Well:
:)Aquifer Recharge �Groundwatcr Rcmcdiation ft. ft.
Aquifer Storage and Recovery E3Salinity Barrier
l9;SAND/GRAVEL PACK:if,a lica'lei _
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage fa ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20i -LLING'I OG'atfech additional sheets:if,neces3ar
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sorOroek e, rain size,etc.)
ft. ft. I
4.Date Well(s)Completed: ell ID# ft, � ft.
5a.Well Location: ft. tt.
ft. ft.
Facility/OwnerAl me ;� Facility ID#f(if applicable) ft. ft.
•L 0 k 10 1'7 10 UO1 i U C I Ce i�A ft. ft.
Physical Address,
City,and Zip ft. ft.
�190bi1CC813 21REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
-7 j q 9 / 22.Certi do
6.Is(are)the well(s)oi Permanent or oTemporary Sign of Certified Well Contractor Da1c
By signing this four,1 herebv cent fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tf this Ls a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or ore the back oflhisform.
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:
9.Total well depth below land surface: 510 SUBMITTAL INSTRUCTIONS(ft.)
For undtiple wells list all depths if different e'erample-3@zoo'mud 2Ql00') 24a. For All Wells: Submit this form within 30 days of completion of well
"If water level is shove casing,use"+" I construction to the following:
Static water level below top of casing: (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 13lELLS 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 n��� the address(es) above, also submit one copy of this form within 30 days of
Amount: 4 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