GW1-2021-00739_Well Construction - GW1_20210401

R, WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Cummings 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3170A �• `"`2
ft. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for ed multi-cas wells OR•LINER ifa""livable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 5/8 i"• .188 Galy Steel
Company Name r I f `r] q/� 16.INNER SING OR TUBING eother"ial closed=too
2.Well Construction Permit#: , �5 WL.t-1 V L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(I ',County,Stale, Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural Municipal/Public ft.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft. ft. in.
Industrial/Commercial oResidential Water Supply(shared) -18:GROUT
I[ri ati0n FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. port Cement Pour
_: Monitoring ORecovery & ft.
Injection Well:
Aquifer Recharge [Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a_livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERI I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG attach additional sheets ifnecessa``
Geothermal(Heatin C oling Return) rtOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiMck type.grain sizes etc
r ft. '7 ft.
4.Date Well(s)Completed: ' _Z 1 Well 1D# It. ®Q ft. 6
Sa.Well Location: 3,'gj+'�S ft. fr.
r- 1v Flsea y�P�� ft. ft. R
Facility/Own r ame t Facility ID#(if applicable) ft. fL t "
Physical Address,City,and Zip ft. ft.
rna`r)C 81�'�1y213E
2L REMARKS :. SS1f1. r
County Parcel Identification No.(PIN) WR SS!7,Y•On
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) •-�(y t 22.Certificatio
/
tF` //el , N / IDI �r ��r W '.4 _!J Z
l
6.Is(are)the well(s)MPermanent or OTemporary t n Certified well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or xMNo with ISA NC'AC 02C.0100 or 1 SA NCAC 02C.0200 Well ConslruMon 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 101 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: A%11 SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: CA J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Mn-multiple wells list all depths ifdii ferent(example-3!t 200'and 2@100') construction to the following:
10.Static water level below top of casing: A (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
12.Well construction method: Rotary above, also submit one copy of this form within 30 days lof completion of well
.e.auger,('t b rotary,cable,direct push,etc.) construction to the following:
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
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 2� completion of well construction t6 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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