GW1-2022-06431_Well Construction - GW1_20220511

7P�Jnt Form,
r W&L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1."Nell Contractor Information:
CHRISTOPHER WATCHER 14rwnTERzoNEs.- -f-
Well Contractor Name FROM I TO I DESCRIPTION
4448A ft.
f t' 11 1 i'1
ft. ft a I_t
NC.Well Contractor Certification Number Ud'1
15-O.UTERECASINGE iiiiultirenieddwells FOR?LINER(ifaa llcatile
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft 6 518 In. .188 G.STEEL
<:16r1NNER CASING OR=TUBING:2.Well Construction Permit#: 5 "eotherm'sl'do§ed
3 (�E LN 2-Z -loo
PROM TO DIAMETER TRICK List all applicable well ronsiruelion permits 7".UIC,County•state,Variance,etc.) R. ft. in.
NESS MATERIAL
3.Well Use(check well use): ft. ft. in.
WaterSuPPlyWell: 17:iSCREEN: � r° -.-_ _ __
Agricultural 13MunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
it. ft. in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single)
IndustriaUCommercial ft• ft. in.
Residential Water Supply(shared) a &,GROUT
Irrigation FROM To
IG
Supply Well: MATERIAL EMPLACEMENT
ENT
Recovery METHOD&AMOUNT
ft- 20 ft. PORT.CEMENT POUR
jection Well:
Aquifer Recharge E3Groundwatcr Remediation ft. &
Aquifer Storage and Recovery Salinity Barrier .'19.1!SAND/GRAYED-RFROM TUL EMPLACEMENTMETNUD
Aquifer Test 13Stormwater Drainage ft. ftExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ZO iDRiLLiNG tiOG attactividditlonal'sheete iGeedessaeothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock e,_rain siz"etc.)
'� ft. / -2 ft-
on-Water Ej
4.Date Well(s)Completed: ell ID# �
5a.Well Location: n• n.
C ft• ft.
Facility/Owner ame ^, Facility 1D#(ifapplicable) ft• ft.
5b I ��e 1 i v i m ft. ft.
Physical Address,City,and Zip ft. ft.
�9 ZI L1?as
oy�Le �O 21ixEt�lARlcs�.__ -
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certiti o
V/ J W
6.Is(are)the well(s)oPermanent or Temporary -�G 7iZ
Si ofCcrtificd Well Contractor Date
7.is this a repair to an existing well: E]Yes or JMNo B thiISA NCAC 02C.0100ebv or*ISAIify that the NCAC 02C.0200)wav(were)constructed in Well Consn•irction Standards and Nat a
Phis is a repair,fill oul known'veil construction information and explain the nature ofthe ropy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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:
9.Total well depth below land surface: � (ft.
Far multiple wells list all depths ifdifferent(example- ea 200'and 2@100') ) 24a• For All Wells: Submit this form within 30 days of completion of well
SUBMITTAL INSTRUCTIONS
-I.,) construction to the following:
jt 0.Static water levelwater level is above casing,low top of casing: all
(ft.) Division of Water Resources,Information Processing Unit,
ing,rtse'•+"
11.Borehole diameter. 6 (in.)
1617 Mail Service Center,Raleigh,NC 27699-1617
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&Infection Wells: In addition to sending the form to
13b.Disinfection a HTH t� the address(es) above, also submit one copy of this form within 30 days of
tyP • Amount, 'E11 ii 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