GW1-2022-06430_Well Construction - GW1_20220511

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
_ i
1.Well Contractor Information:
CHRISTOPHER WATCHER i'4.nWATERzoNEsr .
Well Contractor Name FROM TO DESCRIPTION
4448A ' fL c1 q
ft.
NC Well Contractor Certification Number ft.
15i:0UTER CA81N0,for�mulitle'9sedlweus Olt LINERI sun
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. fL 6 5/8 In, .188 G.STEEL
46ANNER°CASING-OR-TUBING, -eothertnaNetAid loo" y
2.Well Construction Permit#: 5a 3] 4 E�►JZ2 FROM To RI
List all applicable well construction peranUs fl.e.UIC,County,State,Variance,etc.) DIAMETER THICKNESS MATERIAL
ft. R, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1=7r'SCREEN.`
Agr1CUItU181 FROM TO DIAM1IETER SLOT SIZE THICKNESS
�Municipal/Public ft. ft. in. MATERIAL
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single)
ft ft. in.IndustriaUCommercial DResidential Water Supply(shared) .
Irri ation 18PGROUT h_y r
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o R• 20 n•
PORT.CEMENT POUR
Monitoring _'Recovery ft. fL
Injection Well:
Aquifer Recharge QGroundwatcr Rcnrcdiation ft. ft,
Aquifer Storage and Recovery Salinity Barrier 19:SAND/GRi1YEL RACK"if iI Ilcwible
RROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStolmwater Drainage fL %
Experimental Technology oSubsidence Control fL ft.
Geothermal(Closed Loop) OTracer 20?DRIGL'iNGvLOG`attacti 9Wf8onal sheets,tf necessa
_ Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION(color,hardness,saiVrock `e,7 In size,etc.)
0 ft. 2 ? ft. �
4.Date Well(s)Completed: Well ID# 1­ ft. 00 fL r
5a.Well Location: ft. ft.
ft. ft.
Facility/ Name !� Facility 1D#(if applicable) R• %
MAY
1 l e t'ac rt. f1. 62
Physical Address,City,and Zip Yf qq fL ft,
-� n lc e- 1 I b0 Z I Z?2 -11:11EMARKS`=
County Parcel Identification No.(PIN) >�
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one 18VIOng is sufficient) /
3` 0 ,o- �'� i N �?O C�a t 22.Certificatio
(O O r O
6.Is(are)the well(s)apermanent or E Temporary gnalt citified Well Contractor Date
ate ZZ
y signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or MNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
/fthiv rs a repair fill ont known well construction information and crplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of 1his 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (/ (ft.)
For multiple wells/1sI all deputy ifdi(jerenl t�xanhple-3ca 200'and 2Q100') 24a. For All Wets: Submit this form within 30 days of completion of well
construction to the following:
Ijwnter level is above casing,use"+"
f 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 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 SuoDly&Iniectionl'Wells: In addition to sending the form to
13b.Disinfection e• HTH �y the address(es) above, also submit one copy of this form within 30 days of
tYP • Amount:_Z i/'o% completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016