GW1-2021-03051_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
Well Contractor Name FROM TO DESCRIPTION
4448A ft. lgq ft. 12-7
ft. 1+ ft.
NC Well Contractor Certification Number 15.OUTER CASING for mu1G-cased wells rO LINER if a licable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W 2 I — o Oy 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.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft in.
lndustrial/Commercial E31kesidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACE ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Z G ft.
Monitoring Recovery tt. tt.
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 r3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil rock e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: — �2I Well 1D# S ft. 3 ft. a
ft. / a ft. o
Sa.Well Location: C izolloe-rk I I fq-r
t ha Pepe-i—Ap err) Church ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�
ft. ft.1`l E �'I tarn ('Qnr �->r-�,I�e_vr� 0110131
�
J
ft. ft.
Physical Address,City,and Zip (� p '^ Q y�
(l7lL�Ll —I �O bl�C]�lJ 21.REMARKS
County Parcel Identification No.(PIN) t' '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong sufficient)
��/ 1j 1 d a/ 22 fic lion: , 4
6.Is(are)the well(s)oPermanent or Memporary St turc of Certified Well Contractor Date
By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or MNo with I5A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
#'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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'go
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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
^ S
13a.Yield(gpm) i Method of test: Ff"'r 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: Ku completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016