GW1-2022-06428_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only; Fri ih`t Fgrrt '"
1.Writ Contractor Information:
Well Contractor Name FROM TO Y
CHRISTOPHER WATCHER 14S wATER ZONES
:
DESCRIPTION
4448A ft. ft. 1 y t'1 `fir
NC Well Contractor Certification Number ft. ft. 10 ei
15.701UTER;CASiNG-for,inu'Iti'ca`se`.d4vells LINERa if a 'lical le CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. v .ft 6 518 ' In. 188
G.STEEL
6:
�� (��ZiV Z l "eotherinal'd6sed;loo''
INNER_CASING:OR TUBING
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc) ft. ft. i in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17 SCREENS:
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gT Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
RResidentialft. in.
Industrial/Commercial Water Supply(shared)
Irrigation18i_GROiT1. _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring Recovery ft Injection Well: ft
I Aquifer Recharge �Groundwatcr Remcdiation ft. ft.
19:SA1yD/GRA�!EL•PACK Aquifer Storage and Recovery rfa""licatilef_" �t
ery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control fL ft.
Geothermal(Closed Loop) 13Tracer 20i DRILL iNCr LOG'attach addltioiial sheets;if.'necessar :.. .
Geothermal(Heating/Cooling Retum) _;Other(explain under#21 Remarks FROM TO DISC TION(color,hardness,soiUroek e, rain"Size,erc.)
4.Date Well(s)Completed: ID# ft• r t0 ft d
5a.Well Location: ft. ft.
ft.
Facility/OvInepAsInc Facility ID#(if applicable) H• ft. �. ..
17 Zo W AII%c �\_)o.0 Q. 9—(-\ ft. ft. MAY 1
Physical Address,City,and Zip QQ ft. ft. A
�.21 REMARKS r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) pp� 91,
rr //�� 22.Certif�j� ' N1%°J7,q'R0 117
6.Is(are)the well(s)oPermanent or oTemporary Sign of Certified Well Contractor Date
By signing this jorrn,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or EJNo with 15A NCAC 02C.0100 or, 15A NCAC 02C.0200 Well Consiniction Standards and that a
ljthis is a repair.Jill 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 on the back of this forn7.
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:
s SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � � (ft.)
For multiple welts list all depths if different(exan7ple-3Q200'm7d l cQ100') 24a. For All Wells: Submit this form within 30 days of completion of well
� construction to the following:
if water is above casing,use Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
(l "+"
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 27699-1617
(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 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
ZHTH the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: Amount:_ p completion of well construction to the county health department of the county
where constricted.
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016