GW1-2023-01482_Well Construction - GW1_20230209

4W I
WELL CONTSTR CTION RECORD (GW 1) For Internal Use Only: Print Form
1.Well Contractor Information:
CHRISTOPHER WATCHER In
Well Contractor Name DESCRIPTION
4448A
NC Well Contractor Certification Number
1S.OUTER CASING(for multi-eased wells OR LINER if a livable CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft. 6 5/8 in. .188
G.STEEL
16.INNER CA 1NG OR TUBING eothermal close d-loo
2.Well Construction Permit#: 04 � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hvel!construction per•hnrLr(i.e.UIC,County,State.I�ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
Agr1CU1tU131 FROM '1'O DIAMETER SLOT SIZE THICKNESS MATERIALMunicipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) .Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) R. ft. in.
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Mon
Non-Water Supply Well: 0 ft. ZO ft. PORT.CEMENT POUR itoring Recovery ft. ft.
Injection Well:
Aquifer Recharge 13GroundwaterRemcdiation ft. ft.
Aquifer Storage and Recovery QSalinity Barrier 19,SAND/GRAVEL PACK if a livable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStorntwater Drainage ft. ft,
Experimental Technology QSubsidence Control ft. g
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessar }
Geothermal(Hearin Cooling Return) Other(explain under#21 Remarks) FROM 1'o DESCRIPTION(color,hardness,soi0rock e, nin size,ate.)
ft. ft.
4.Date Well(s)Completed: ���" ZZ i
We11ID# 2 et. tJ� ft,
5a.Well Location: {� ft. it.
U�1�(1�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft
cc r,
�D O(� 1,1t)0� 211.-R'EMARKS
ounty Parcel Identification No.(PIN) V�/ d
Ow
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �j(9
(if well field,one lat/long is sufficient)
: � O e f J/✓/ N - y 3 / 22.Ccrtitic '
Lp / W /
6.Is(are)the well(s)e)Permanent or ElTemporary Signature of d Well Contract r
Date
7.Is this a repair to an existing well: Elves or JMNo Withh15AhAtCAC 01C.0100g this forin,I ea*1SA/NCAC 02C.0200ify that the )Well C was o s7racNonrrStandards and a
repair
it a repair,fin!out known well on
information and eXplain the nature ofthe copy of this record has been provided to the aril oxner.
repair under#1/remarks section or ah 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
t 1 SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: 500
For multiple wells list all depths lfderent jeranhple-3@200'and 1©lOOq (f t') 24a. For All Wells: Submit this form within 30 days Of completion of well
construction to the following:
10.Static water level below top of casing: (tt.)
ifwater level is above casing,ore'•+" Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For lniection Wells: In addition to sending the font to the address in 24a
12.Well construction method: ROTARY above,also submit one copy of this fonts within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) D Method of test: AIR ROTARY 24c.For Water SuoDly&Iniertion Wells: In addition to sending the form to
13b.Disinfection the address(es) above, also submit one copy of this form within 30 days of
type: HTH Amount: G'Q0Z completion of well construction to the county health department Of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources
Revised 2-22-2016