GW1-2021-00735_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Christopher Cummings 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 2 � Q 2
3170A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a cable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 2 ft. 1 6 W8 in. .188 Galy Steel
Company Name
Gtt �� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: �45`-i� 10 r-LN ZQ FROM I TO I DIAMETER THICKNESS MATERIAL
Ltsl all applicable well constriction permits(i.e.111C,('mmly,Viole, IAartance,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 Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) 12Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) ts.GROUT
711rrimfion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft* 20 fL Port Cement Pour
Monitoring Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge Ociroundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier ., FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return) FROM TO DESCRIPTION(color,hardn soil/rock rain siu,etc
Other(explain tinder#21 Remarks) D ft. �� i+-fr.
4.Date Well(s)Completed: 1:���Well 1D# /� ft. SSc- ft' n �� a j
5a.Well Location: 3S` ft. 27 ft. ocl Cs
ft. ft.
i�YtC I t E �C-
Facility/Owner ame Facility ID#(if applicable) ft. ft.
L40Q9 Ma&.y)2� 1�r tt2-vff 2i7aS&' ft ft ,
Physical Address,City,and Zip f ft. ft.
IIT\C�j�/1&Ac e- �,o Z�3u$"t 5 2L REMARKS
Cowry Parcel Identification No.(PIN)
lnlultnjtium t- =-a
sinq Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: erS-nilnn
(if well field,cone lat/long is sufficient) 22.Certification
;,e
Co. 7(06 N �q° 1 '�' 7q w
it
6.Is(are)the well(s)oPermanent or Temporary ure of well Contractor Date
y.signing this form,I hereby certify that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JRNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lmown well construction information and explain the nature ofthe copy oflhis record has been provided to rile well owner.
repair under 1121 remarks section or on the hack 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: Z90-(ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
inle wells list all depths if different(example-3Q200'and 2 t@
l iu ntuh100')
2 construction to the following:
10.Static water level:below top of casing: "/ (ft.) Division of Water Resources,Information Processing Unit,
l(waler level is above casing,use"•" 1 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
12.Well construction method: Rotary above, also submit one copy of this form within 30 days of completion of well
auger,r construction to the following:
(i.e.au g 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: Air Rotary 24c. For Water Supply&Iniection 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: _700z 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 Water Resources Revised 2-22-2016