GW1-2021-00741_Well Construction - GW1_20210401

V1 LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Christophere• WCA��
14:WATER ZONES
Well Contractor Name FROM TO I DESC IPTION n
ft
� ft. It.
NC Well Contractor Certification Number IS.OUTER CASING.for multi cased-wells OR LINER if.a livable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 & ft- 6 5/8 in 188 1 Galy Steel
Company Name
p 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3 11y q I w r to FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) It. 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) OResidential Water Supply(single) ft. ft. in.
industrial/commercial JEResidential Water Supply(shared) I&GROUT
ITTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well- It. N%ft. Port Cement Pour
_: Monitoring [3 Recovery ft. ft.
Injection Well: ft, ft.
Aquifer Recharge 00roundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStotmwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionaPsheets of necessary),
FROM TO DESCRIPTION color,hardness soil/rock a rain size,eta
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) ,
ft.
4.Date Well(s)Completed: — "11 Well ID# 35.,-Ift. ZOO ft. 0Ci
5a.Well Location:
ft. ft.
!-_�*Ul1 �l3wtiA , tt ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
AAW
314� 5 . N�a w�,y l•�w �.ivlr r �7�s8 ft. ft. � X
Physical Address,City,and Zip .r ft. ft. ^ BvSt(1f�
I�w�ancz 128021 U Ito 0 21.REMARKS 3 r IOf►
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ) (� 22.Certirteati
3G° ©�tp��J 1 N / �� �O 1
W
6.Is(are)the well(s)oPermanent or OTemporary Signatu ertifie ell Contractor Date
Hy signing this join,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or JRNo with 15A NCAC'02C.0100 or 15A NC.'AC:02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofihe copy ofthis record has been provided to the well owner.
repair under tt21 remarks.section or on the back of thisform. 23.Site diagram or additional well details:
S.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 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
Por multiple wells list all depths if different(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing: 3a (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 m.
( ) 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
(i.e.auger,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) 11_S Method of test:Air Rotary 24c. For Water Supply&Inked In Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: OB-I— completion of well construction toi 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