GW1-2022-10091_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD!GW 11 Pr(nt Form
For Internal Use Only: �a.�..,.�
I,Wag Contractor Information: I
CHRISTOPHER WATCHER
Well Connector Nam- 14.WATP.R 7ANE5
440A EOM TO DFSCRI ION
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NCW-Il Cootnctor Caniflcadon Nlntb-r R• f4
CUMMINGS DEVELOPMENTS, INC 19.OUTBRCASING formdtleaaa we05)ORLINER If Cable
Cum an DRUM DIAMETER
P YN-me t R TU h. TNICK.vegB MATERIAL
85/8 in• .IN
2•Well Contraction P `► X WELN z.2- 16'uvN� ING OR TUBING Nth" al cloud-loo G.STEEL
Lire all gpp(irah/r rw/(ronatre umio a• S� FROM TO/rerWY(L[.U2C(,'jaeb•At1 talons, DIAMETER THICKNESS MATERIAL
3.Well Use(cheek well me): R' AL i-.
Water Supply Well: f. rt. in.
17.817tggN
A�LvI Geothermal(Rating/Cooling Supply) OMunicijermblic PROM TO DIAMETER a L
rt. OT SureTHICKNESS MATERIAL
Residential Water Supply R• I°'
IndustliaVCommercial PP Y(Single) R.
ORuidendid Water Supply(shared) u, in.
kri lion 18.0 ROUT
lgoa-Water Supply Well: FROM TO MATERIAL
Monitoring 0 ft. 20 R. EMPLACEMENT METHOD A A.NOUNT
Recovery PORT.CEMENT POUR
action Well: R• tL
Aquifer Recharge OGroundwatcr Remediation R• fL
Aquifer Storage and Recovery OSalinity,Bonier 19.SANDIGRAVI3.PACK its Is
Aquifer Teal FROM TO MATERIAL OSInfI11Wa[er Dr8lnage R It.
EMPLACEMENT eIETNUn
Geothermal( Technology OSubsidence Control
Geothermal(Closed Loop) rt• R
[]Tracer 11 DRILLING LOG Nt nce additional sheen,ifneceuar
Geothermal Heatin Coolin Return) Other aE lain Under N21 Remarks
n �f FRrtO�M TOYS DFACRIYITON
ft. Ir-lee.horanesa,wiarora a min du,elr.,
4.Date Well(a)Completed: / 17-Z Z v J R'
Well IDq s
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Sa.Well Location:
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1J[ACO I d rc R n 't\ �T
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FscmUiOwm Name Facility IDS lifspplicahlc) R.' Is.M..5T. T
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Co-nty 8>1'9 r r e 7'1 9 a :1.ReRfARrfg _
Panel Idend6cation No.(PM)
Sb.Latitude and longitude in degrees/mleotedeeronds or decimal degrees: Una
tlfwell field,o-o l 0als is sufficient) q pW��
3JO O . &q� ' N 1 /O Z�• I 1 22.Certille n.
W (� e 6.Is(are)the well(s)OPerinaoent or OTemporNry into
N Wd1 Conha
7.la this a re air Date
P t0 an existing wag: Oyes or EON, ay a8+Air fans,/hr'rO err/(jy Aw+Art air(/fx)war(wrrrl ronrlrnc+rd In ncrordaucv
f+Au it a repair,f111 oar kno""17'A"'"""A lgforqr-+ion and erplaie,Art nulurr o ro 15A NCAC 02C.0100 or/SA NCAC 02C.a260 Wd/Cgnr
repair under 82/remark recrian or ore the back olrhb form. PY/ erord Iraq Arne provided m rhr art/oanec "Ilion STandadr and(Awl a
S.For Geoprobe/DPT or Cloud-Lao 23.Site diagram or additional well details:
construction,Only 1 GW- P irate TOTAL Wells having the same You may use the back of this page to provide additional well site details or wdl
Y I is needed. Indicate T01'AL NLRvIBER of wells conhuction details. You may also attach additional pages if necessary.
drilled; /�
9.Total well depth below land surface: •2 40 SUBMITTAL INSTRUCTIONS
F"nutllip/r"its list all depth,tfd(lrrm,,,Nanp/o-3(o)200'md20/00') (O-) 24a. for All Wells:
Submit this form within 30 days of completion of well
10.Static water level below top ofeasing: Z/ construction to the following:
!lwarcr lave/is gAovecmiag.no-••.• (ft.) Division of Water Resources,Information Processing Unit,11.Borehole diameter:6(in.) 1617 Mall Service Center,Raleigh,NC 27699-1617
to
12.Well construction method: ROTARY above also submittt onelcopy of this form thin formdays of completio oin 24a
gager,rotary,cable,dircer push,etc.) colistme[ion to die following: f well
FOR WATER SUPPLY WEL Method of teat: AIR ROTARY 9ALS ONLY: Division of Water Resources,Underground Injectlon Control Program,
(gP )---
13m.Yield m 3 1636 Mail Service Center,Raleigh,NC 2761636
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—0 24c. For Water Suodv A Injection Well
ll: In 13h.Disinfection the address(es) above, also submit one copy of whist form on to sending
nil 301days��}•
typo' FI Amount: U2
completion of wall conatnmtion to the county health department of the county
where constructed.Form GW-1
North Caroline Doparmcm ofavimarriMal Quality-Division of Wator Resources