GW1-2022-08339_Well Construction - GW1_20220511

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER
:34:WATER'ZONES
Well Contractor Name FROM To DESCRIPTION
4448A ft. rr. 2 1P 15 7 2
ft. ft.
NC Well Contractor Certification Number 115.OUTER'CASING for`multi cased wells;OR LINER{ifra"lice6le
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. fL 6 in. PVC
Company Name
/1��^ I&INNER.CASINGORT.UBHQG'i(`eotherrilahcloseil=loo" _ '`"'--'
2.Well Construction Permit M (n7 a0 -- Oo'1ST FROM I TO I DIAMETER I THICKNESS TMATERIAL
List all applicable well construction pernlitS fl.e.UIC,County.State.Variance•etc.) ft. ft. in.
3.Well Use(check well use): ft. % '°•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE: I THICKNESS I MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared) _ _-
]&GROUT'_!.
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl- 20 fL PORT.CEMENT POUR
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
;19.'SAND/GRAVEL PACK d-4661 cable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20:DRILLING.LOG attach additl'oiiehsheets.if.recessai."- -
Geothermal(Heating/Cooling Return) _I Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soWrock type,grain sire,etc.)
0 ft. ft. -
. I
4.Date Well(s)Completed: 'Q'2 Z Well 1D# 2 ft. 2'7/ 0 ft.
5a.Well Location: R. ft.
Ga I� �' ft. ft.
Facilitty/OJwnerNamc Facility ID#(if applicable) ft. ft
of
ft. ft.
Mar I^.�o orL
Physical Address,City,and Zip pQq, r�p �y, 1 ft. ft.
MAY
g. 1`1 "I b .'7 1 b L•1C 11.REMARKS'..
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrc o
36013198`P I N 79a DP r ESN� W �
3-i2-�
6.Is(are)the well(s)oPermanent or Temporary ignaturc ifie ell C tractor Date
signing this form,I herebv cerlify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with l5A NCAC 01C.0100 or, 15A NCAC 01C.0100 Well Construction Standards and that a
/#'this it 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2;1 / O at.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwitiple wells list all depths if different(example-3 cCd200'and 1Q100') construction to the following:
10.Static water level below top of casing: 23 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the forth 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:
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&Injection Wells: In addition to sending the form to
�J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: h Va Z 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