GW1-2021-05788_Well Construction - GW1_20211025

k'P�it Form;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
D
Well Contractor Name FROM TO ESCRI •IONft. ft. OILd A
4448A v
rr. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name � ft
+1 f[. . 6 5/8 in. .186 G.STEEL
11 1.1 n, 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: � L4 tPJLv W E LN Z i' FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
j Agricultural []Municipal/Public ft. ft. in.
]Geothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft. ft. in.
Industrial/Commercial E Residential Water Supply(shared) 18.GROUT
7ij Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft PORT.CEMENT POUR
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge IDGroundwatcr Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _JOther(explain under#21 Remarks) FROM TO DFSCRIP ON(color,hardness,soil/rock type,grain sim,etc.)
4.Date Well(s)Completed: ' 'Z i Well ID#
Sa.Well Location:
ft. ft.
Nen��.� 4�bMe_5 tun-�1na.r� OZ
Facility/Owner ame Facility ID#(if applicable) ft. ft.
5005 }-t ar ve `1 V►L,)a _r �. yw.bw _ a�3 o a ft. rL UnA
Physical Address,City,and Zip ft. ft. V)IO
e_ `�glort'S8'tlo 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
,00ne
�latt//lloong is sufficient) �'/ /- 22.Certification:
%05f. g01 N __l90 �10' Y-710 W o ny
6.Is(are)the well(s)0 Permanent or Temporary Signatur Ccrtiftc on actor Date
By s' ning t form,!hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or �No w' 115 CAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the o, of this record has been provided to the well owner.
repair under#21 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-I 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-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 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 th is 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)_6Method of test: AIR ROTARY 24c.For Water Supply&Injection 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: lea z, 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