GW1-2021-03050_Well Construction - GW1_20210620

Print Form
-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 7
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTIO
ft. ft. (D 3 W 7 co
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. (t 6 ft. 6 in. PVC
Company Name l.i
- O � lti.INNER CASING OR TUBING(geothermal closed-too O
2.Well Construction Permit#' (� 3o 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIA I.
Agricultural OMunicipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) FkResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. zo ft.
Monitoring IlRecovely ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sim,etc.)
O ft. to ft
J
4.Date Well(s)Completed: 5`t3"v Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
cEIVED
� CL�t�% s It, 27,231 ft. ft.
Physical Address,City,and Zip ft. ft.
d)yJ 7� 21.REMARKS
'1 1 Intorma Ion
County Parcel Identification No.(PIN) ion
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneellat/long iiss sufficient) �+� p 22.Certification'
6.Is(are)the well(s)oPermanent or 13Temporary Signature ofC lfie ll ontractor Date
By signin form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or Jallo with 15 I CAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this 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/Iris 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
(l
9.Total well depth below land surface: I v I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3@200'aid 2@100') construction to the following:
10.Static water level below top of casing: Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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
n 13a.Yield(gpm) Method of test' #4'14kV 24c.For Water Supply&Iniection Wells: In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: N U Z completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016