GW1-2022-06544_Well Construction - GW1_20220511

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SELL CONSTRUCTION RECORD(GW 1) Prmt Form
For IntelTral Use Only:
4•Well Contractor Information:
CHRISTOPHER WATCHER
-14.WATER ZONES
ell Connector Name FROM TO DESCRIPTION
4448A ft. ft.
NC Well Contractor CertificatiDo Number ft. ft.
15::0UTERiCASING(foe multi-cased,Wells OR LINER if a`licatile'
CUMMINGS DEVELOPMENTS , INC FROM TU DIAMETER THICKNESS MATERIAL
(-nipany Name +t ft. ft 6 in,
' PVC
^' 16:INNER' SING OR TUBING eothermal closed=loo 2.Well Construction Permit#:- I gotd FROM TO DIAMETER I THICKNESS 1 MATERIAL
tall applicable well construction pernnls(I.e.b7C,County,State,Variance,etc.) ft. ft. in.
3� Well Use(check well use): ft• ft. in.
rhIndustrial/Commercial
Well: SCREEN,
l FROM 'to DIAMETER SLOT SI%E 'THICKNESS MATERIAL
Municipal/Public ft. ft. in.
(Heating/Cooling Supply) Residential Water Supply(single)
otnmercial ft• ft. in.
Residential Water Supply(shared) 18:GROUTUpply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 20 f. PORT.CEMENT POUR
Monitoring DRecovery
1 jection Well: ft• ft.
Aquifer Recharge Groundwater Remediation
(Aquifer Storage and Recovery Salinity Barrier 19•SAND/GRAVEL PACK,if a" lica ble),
FROM TO MATERIAL EMPLACEMENT METHOD
(IAquifer Test [3Stomtwater Drainage ft. ft,
I
Technology DSubsidence Control ft, ft.
eothermal(Closed Loop) Tracer 20:DRILLING LOG'(attach additional sheets ifnecessa
_ eothermal(Heating/Cooling Return) 110ther(explain under#21 Remarks) FROM TO DESCRIPTION tealar,hardness,sorUrock type.grain sirx,etc.l
10 ft. / rL
_q
4.4Date Wells)Completed: ZZ Well ID# ft. ft.
Sa r1)
Well Location: ft. tt.
i 1L r it. ft.
Fa ility/OwncrNamc Facility ID#(ifapplicable) ft• ft.
I
old u Flo N nr 11 ft. ft.
Ph�sical Address,City,and�Zi F
ft. rt. Inforntatiort Pr
oeerssin�Ul�lt�ltWeI\ O OLA 00w)01C00000 '21.)ZEMARKS.
County Parcel Identification No.(PIN)
5b�Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one W/long is sufficient)
� <y. N '
22.Certiric� .9y(�
W 3_q-zZ
6.l?s(are)the well(s)oPermanent or oI Temporary gnaturc of Cc 'led Well Contractor Date
By s' ig this form,/herenv certify that the well(s)was(were{)constructed in accordance
7.Is this a repair to an existing well: E)Yes or EjNo uh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 i/'ell Construction Standards and that a
/f lltis is 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 a•on the back of this far nr.
23.Site diagram or additional well details:
8.Igor 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/ Zd SUBMITTAL INSTRUCTIONS
9.'Rotal well depth below land surface: `� (ft.)
Fa ,w/tiple walls list all depths if different(example-3Q2o0'aid 2Qro01 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:
If,v�orehole
It level is above casing,trse"+'• (ft•) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11. 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.1uger,rotary,cable,direct push,etc.) construction to the following:
FOI WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.iYield(gpm) !JI 7 Method of test: AIR ROTARY
24c.For Water Simply&Iniection) Wells: In addition to sending the form to
13b.Disinfection type:
HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: OZ• completion of well constriction to the county health department of the county
where constructed.
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Form1GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016