GW1-2023-01490_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD GW_I Print Form
For Lrternal Use Only;
I- Vell Contractor information:
CHRISTOPHER WATCHER
Well Contractor Name 14.WATER 4448A ZONES
FROM .1'O DESCRIPTION
ft. ft.
NC Well Contractor Certification Number ft. ft.
15 OIUTERCASINC(formulti-cased wells ORLiNER if Ucable
CUMMINGS DEVELOPMENTS , INC
TO DIAMETER THICKNESS MATERIAL
Company Name +) k. IL
8 5/8 In. .788
2.Well Construction Permit#:
16.INNER CASING OR TUBING(eothermsl cloaed400 G.STEEL
_��� •— O„�fl
List all applicable well eonstrartion peimas r.r.UIL,Coarty.State.Yarianre,err.) FROM ft. TO ft, DIAMETER in. THICKNESS
MATERIAL
3•Well Use(check well use):
ft. ft. in.
Water Supply Well:
17.SCREEN
Agricultural FROM To
Municipal/Public DfAtNETin SLOTSIZE THICKNESS MATERIAL
Geothe7 1(Heating/Coolin Supply)
u 1 n' ft• in.
g PP y) JaResidential Water Supply(single)
Indusn•ial/Commercial QResidential Water Supply(shared) in.
Irri*anon 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring 0 ft- 20 ft. PORT.CEMENT POUR
lGeothennal
Well; Recovery ftft.
quifer Recharge 0Groundwatcr Remediation ft.
quifer Storage and Recovery QSalinity Barrier 19•SAND/GRAVEL PACK ifs licable)
quifer Test FROM TO OStorntwaterDrainage (t, ft. EMPLACEMENTMETHUDxperimental Technology QSubsidence Control
eothermal(Closed Loop) �Ti'acer0.DRILLING LOG attach additional sheets ifnecessa(Heatin Coolin Return) Other'(explain under#21 Remarks) FROM ft. TO,
DESCRIPTION(co(color,hardnrss,"WrackocY 0.grain doe,tic.)
_ / ft.
4.Date Well(s)Completed: Well ID# oV p i O 1•
e. R' U
5a.Well Location: e
tt.
dv1 ft• tr.
Facility/Owner Name Facility ID#(rifapplicable) ft. n•
5t1as IL� C4Tl1RY n• it.
Physical Address,City,and Zip
LCCU�_ ��
O£ �{�'rp� 21.REMARKS
"
Parcel Identification No.(PIN) vV f I I f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O f
(if well field,one]at/long is sufficient) �y
22.Certificati
W
6.Is(are)the wen(s)OPerntanent or Temporary ignaturc of S`Z 7--Z Z-
Wcll Contractor Datc
7.Is this a repair to an existing well: Yes or @No B nnrg this farm,1 hereGv certify that the ivell(e)was(were)constructed in accordance
/Ithis it a repair,f!l one known well coustrictlon infoi•atation and erplain the nature ofthe /! Ithis record has been provided to the well owner.
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 fYe!!ConshtR'1lot Standards and that e
repair under#11 remarks section or on the back of this form. co v a
am or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You
may a the back of this apagelto provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells You rna
drilled: 500
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
Par ntulNplr Rills list all dept/is;f d fjerent(cramp ee-3ca 100,and-@Ioo') (ft•) 24a. For All We l : Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following:
ffwater level is above casing,use••+• (ft.) Division of Water Resources,information Processing Unit,
11.Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
ROTARY 246.Fo
12.Well construction method. r Iniection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this fond within 30 days Of completion of well
6-C.auger,rotary,cable,direct push etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
a 1636 Mail Service Center,Raleigh,NC 27699-1636
ys of
13a.Yield(gpm) AIR ROTARY
Method of test: 24c.For Water Suool Iniection Wells:13b.Disinfection the addresses) above, also submit one copyIn addition to sending the form to
type' Fi Amount: .S 4 Z completion of well construction to the county health of s form departm department the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20 16