GW1-2021-00736_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
J.VI,eDContractor Information:
r
Christopher Cummings 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. g, 1 L-s L 4•f3►
3170A ft, ft, t
NC Well Contractor Certification Number I&OUTER CASING. for multi-case&wells OR LINER(if.applft6ble
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
+1 ft ft• 6 5/8' i" A 88 Gall Steel
Company Name
i 'Wr l 16.INNER CASING"OR TUBING. 'eothermal closed-loo'
2.Well'Construction Permit#: 4 LA I LA G LN w FROM I TO DIAMETER I !THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,Stale, Variance,etc.) ft• ft. in.
&Well Use(check well use): ft. ft., in.
Water Supply Well: 17._SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
!Agricultural [3MunicipaVPublic fa ft. in.
:)Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 1S.GROUT
.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- Port Cement Pour
- Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if,a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 10.DRILLING LOG attach additional sbeetsif necessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rack type,arain size,eta
ft. ft. 1
4.Date Well(s)Completed: 7- •ZI Well ID# ft. 2S ft- UnC"Sbl0c1r
2 S ft. 7 i ft.
5a.Well Location: 2y
I
�j ,ESJI ,L-J,J"Door
oor s ft. ft.
t
Facility/Owner Name Facility ID# if a licable ft. ft.
o-t$33 C^fleA� CL5vA Srwu� 37 ft. DR
ft
Physical Address,City,and Zip ft. ft. N X
to y\C� S 8 7 9 t ie 0 3t� 21 REMARKS' iy
County Parcel Identification No.(PIN)
6 III +Ofi i CCU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlongg isCsufficient) i I 22.Certification:
3S°52.. � N -la—l* 72-31 Z W
6.Is(are)the well(s)mx_ Permanent or OTemporary Signature Certif a Contractor Date
&� By is form,/hereby certify that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or InNo w 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to�lhe well owner.
repair under#21 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: V� (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: 43 Division of Water Resources,Information Processing Unit,
/Jwaterleve!is above casing use"-r." 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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: Air�Rotary 24c. For Water Supply&Inject on 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: �OZ 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
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