GW1-2022-07601_Well Construction - GW1_20220817

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FELL CONSTRUCTION RECORD GW I Pr(nt Foam`
Use -
1.Well Contractor information: For Internal Only:
CHRISTOPHER WATCHER
Well Contractor Name 14:WATER ZONES s ;,
FROM TO DESCRIPTION~
4448A R. ft.
tr. i $I
NC.Well Contractor Certification Number R. O 0 )110
CUNNINGS DEVELOPMENTS, INC 1s:ouTER CASING for.m—Wd ceied,wells:OR•LiNER if(6' licahle FROM TO DIAMETER Co THICICNE68
mpany Name +t R u MATERIAL
7 Z. R' 6518 In. 188 t3.STEEL
2.Well Construction Permit#: 5 3 1)�FLN Z Z 16 1NNER� ING OR TUBING. eutheii.188sed loo
List all applkable+yell constrartion peirnlle r e.UIC.County,State,Varlanre,etv.) FROM TO DIAMETER _s
R. TAiCKNESS MATERIAL
3•Well Use(check well use): ft. in.
Water SuPPIY Well: ft. f7' in.
-17.SCREEN.
Agriculttual E)Municipal/Public FROM TO DIAMETER `BLOT 617.E THICKNBBS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Su I ) R. R' io.
Industrial/Commercial Supply(single)g R.
Residential Water Supply(shared)
Irrigation 18:GROUT
Non-Water Supply Well: FROM TO MATERIAL
Monito 0 fL Ye EMPLACEMENT METHOD&AMOUNT
ring R• PORT.CEMENT POUR
InjectioD W ;Recovery
R. %
Aquifer Recharge Groundwater Romediation R' R•
Aquifer Storage and Recovery Salinity Barrier 19..SA1VD/GRAVEL PACK if g ncable s
Aquifer Test FROM To MATBIL RIAL
Stomiwater Drainage fL EMPLACEML,rr METNOD
Experimental Technology �
Geothermal(Closed Loop) Subsidence Control rt.
Trace[ 20."DRILLiNGLOG'9ttschaddIitonelial11,11faeeelsar '*
Geothermal astir Coolie Return) Other a lain ender#21 Remarks) FROM To =. '
O DEBCRIPTION(color hardn IalUroeI 4 dze,etc.
4.Date Wel(s)Completed: Z Z R. 27 R.
ell ID#
Sa.Well Location: 27 R• Z 00.IL G
N��'EUP �'TM—Z�� R. rL ,P•�
Fealty/Owner me
Facility IDIt(ifapplicablc) R. ft.
Physical Address,City,and Zip Z —
County
Fv � Y D � �_ '21.REMAR". n Pr:=C,B4,�StFJ Urt
Pored Identification No.(PIN)
511.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,ono 130oonng is sufficient)
3&o / N 7 9 0;fib•a'l� 22.Certitic '
W
6.Is(are)the well(s)OPermanent or E3Temporary of Ccnificd Well Contractor 6— Z 3—�
7.is this a repair to an existing weB: Yea or By signing thte jorn+,I herrbV ceM(fy t1uN the tvell(s)was(watt)constructed In acewdancr
rlPai Le a er 021 pll onl known wr/!cons it On 11 o+nmllon andeXplalu the nalurn of hr spy of Nets earned has Gres provided to Ibe xet. 2
Kith!SA NCAC 02C.0100 or!SA NCAC 02C.0200 We!!GonslnrcNon SJandmrls mid Ihal a
repair under ll21►rmar/rs sectfa+or en the back oflhlajor+n.
tsar.
S.For Geoprobe/DPT or Closed-Leo 23.Site diagram or additional well details:
construction,only I GW-1 is needed, Indicate TOTAL webs having the same You may use the back of this page to provide additional well site details or well
drilled: NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTSI INSTRUCTIONS
For multiple we/!s list aft depths if di
.fferent(rxan+p/�3Q200'and 2C3a too► (f t') 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following:
jwarer level Is above erasing,tsve +" (fL) Division of Water Resources,Information Processing Unit,II-Borehole diameter; 6 1617 Mail Service Cente
(in.) r,Raleigh,NC 27699-1617
12.Well construction method: ROTARY 24b.For infection W 11a: in addition to sending the form to the address in 24a
(i.c.uu cr,rot above,also submit one copy of this form within 30 days of completion of well
g ary,cable,direct push etc.) construction to the following:
FOEWATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a Z Y 1636 Mail Service Center,Raleigh,NC 27699-1636
1°) Method of test• AIR ROTARY
24c.For Water Suooly&�tr actionWells• form to
13bon type; HTH the address(es) above, also submr1 t one Dopy of this form on to Sending
Oe days of
Amount: Z6O Z completion of well construction to the county health department of the county
Form OW-1where constructed.
North Carolina Departntcnt of Environmental Quality-Division of Wator Resources