GW1-2022-06551_Well Construction - GW1_20220511

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CH RI STOPH E R WATCHER 14.WATER ZONES
Well Contractor Name FROM 'f0 DESCRIPTION
4448A ft. ft. LP : 9 0 (_ @
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THIpCKNESS MATERIAL
+1 ft. r ft. a lj� i in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E Municipal/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring ®Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain six,etc.)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) 0 ft. ft. So�
4.Date Well(s)Completed: ��?J-oZal Well ID# It. ft. otl
5a.Well Location: !2,& "L ft. o,,
—ft. ft. V��o•�so 1 a- ��c..A �vc�
Facility/Owner Name Facility ID#(if applicable) ft. !, ft. {z 5 C
,Po 5 Harmer 4aLK nLgA ��L d 5i l-,r Ci� ft. Cf rt. t
Physical Address,City,and Zip ft. ft.
D _� 0—a 2_54
5'7 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DwQfBw
(if well field,one]at/long is sufficient) 22.Cer'
ZL
6.Is(are)the well(s)oi Permanent or OTemporary S' ure of tcd ell Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to.the well owner.
repair under#21 remarks section or on the back o/'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: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:0'
10.Static water level below top of casing: J 4 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 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
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ( ®L. 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 Watcr Resources Revised 2-22-2016
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