GW1-2022-08344_Well Construction - GW1_20220511

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: k
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION j Ly
4448A
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells OR LINER if a Iicable
CUMMINGS DEVELOPMENTS , C FROM TO r DIAMETER THICKNESS MATERIAL
+1 It. 11011
Gill ft. 6 in. PVC
Company Name Yc
16.INNER CASING OR TUBING geothermal closed400
2.Well Construction Permit#: W Qol - ODaa 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 SLOT SIZE THICKNESS MATERIAL
Agricultural _;Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 it PORT.CEMENT POUR
Monitoring ORecovery
Injection Well:
Aquifer Recharge Groundwater Remediation ft.
SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery �Salini hBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/mck e, rain si x,etc.)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) 0 ft. � ft.
6/� (.f I'"l
4.Date Well(s)Completed: '�Z Well ID# �G� ft. .� It.
t-it
r
5a.aa..Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable)
H I ll T8 ft. ft.
Physical Address,City,and Zip ft. ft. W40fg7"W PrOC V1111
DI aM L V/ S� 4Ss 7/_ 21.REMARKS
County I Parcelldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) ( 22.Certific n•
G W I'acly N —79° II r 0-20 w
6.Is(are)the well(s)oPermanent or OTemporary Signal Certified Well Contractor Date
By signing this form, I her•ebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or oil 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Infection 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 SUPPLYY/WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) dA, Method of test: AIR ROTARY 24c.For Water Supply&Infection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: � /q�. 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