GW1-2021-00738_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Christopher Cummings 14.WATER.ZONES
FROM TO DESCRIPTION
Well Contractor Name ft, ft. n.
ry qV
3170A ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING.for multi-cased-wells OR LINER flfau`licable
Cummings Developments, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
+1 ft y - ft' 6 5/8 in' 188 Galt Steel
Company Name
0o 16.INNER CASING OR TUBING eothermal closed=loo
2.Well Construction Permit#: A w t-: ro FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,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 [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 & Port Cement Pour
__ Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK(ifitimlicablO
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 10.DRILLING LOG attach additional sheets if necessa.
FROM TO DESCRIPTION color,hardness,soillrock rain size.eta
Geothermal(Heatin Cooling Retum) _�Other(explain under#21 Remarks)
O ft. Zap ft.
4.Date Well(s)Completed:►- a► Well ID# fL 42,0 IL
rr�l
5a.Well Location:
ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ?> '
ft. ft.
a •
,;laR Elmo o t a oxa_y CIII IaIn A Vli a � 202
Physical Address,City,and Zip ` % ft.
AER
PACA rVV)h(e aUg g g i ci 4 5 21.REMARKS
County Parcel Identification No.(PIN) i'i)n Pro" 1 tJ i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ta�ttlong is sufficient) �j 22.Certification:
3V 13. s Si I N /v Z7r 12 1
6.Is(are)the well(s)oPermanent or OTemporary Si ure o ified ell Contractor Date
signing this form, I hereby certify that the we//(v)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or E)No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If(his is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 621 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:_ (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 ref 200'and 2@100') construction to the following:
10.Static water level below top of casing: /0 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
13a.Yield(gpm) ✓ Method of test: Air Rotary 24c. For Water Supply&Injection`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: 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