GW1-2021-03085_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. � / Z�C�
4448A I ' l3
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER if a Ileable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft' ft' 6 5/8 In' 188 STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Z{ 00 7-3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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 [3Municipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1S.GROUT
lrri ation FROM TO MATERIAL EPIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t1(-I rl
Monitoring ORecovery
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Rcmcdiation
19,SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM 1'0 DFSC TION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) U ft. y/ ft.
—,a i
4.Date Well(s)Completed: 7 Z� 1Q�1 Well ID# �ft. ft. 0 'l J,6 IiGr/4 c 44t
5a.Well Location: 4041ft. f ft. �G
�' I C�» 0O0 J EiA a ft. ft.
FacilitylOrwncr Name
y�q Facility ID#(if applicable) ft. it.
kto i/o /-se-mM &I 2757P ft. ft.
Physical Address,City,and Zip ft. I ft.
daYaA- O ato fisa4 21.REMARKS
County Pat-eel Identification No.(PIN) nVyR SedOn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certiffcatio
7./4 L
6.Is(are)the well(s)MPermanent or Temporary Signal of Cc ' d Well Contractor Dat
By signing this form,I herebv certify Thal the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or E)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200{Nell Construction Standards and that a
Ifthis is 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'lhis 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: SUBMITTAL INSTRUCTIONS
Q'1
v 9.Total well depth below land surface: v Ot.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/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,
Ifwater 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 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 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: '�^0 t��, completion of well construction to the county health department of the county
where constructed.
Fortin GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016