GW1-2021-05972_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO I DESC "ION
4448A ft. 4t- Ito(0
ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER ita licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 5/8 rn' .188 G.STEEL
Company Name ` rI 16.INNER C SING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 0 l Z ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft ft in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R• 20 ft PORT.CEMENT POUR
Monitoring Recovery
Injection Well:
Aquifer Recharge ❑Groundwater Rcmediation ft. ft.
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) O ft. ft.
4.Date Well(s)Completed:.10- 13 '2 Well ID# 219 ft. ft.
5a. \Well Location: ft. ft. IVO
�Vt D Cy riV(__V IV
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
koQLk 1=r;�i C'�.a-j�1e1 H:�t a1 S-ILe ft. ft. OC
Physical Address,City,and Zip ft. ft. ICCeSs1�
11 3 k ( s 7 a 21.REMARKS 0 C1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certificatio
3S° �8. N ?Ta12. y3`I( � w
6.Is(are)the well(s)oPermanent or OTemporary S' are of cc ell Contractor Date
By g this form,1 her•ebv certify-that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: E,Yes or E)No ith 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 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 I 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: 1 ,/ (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
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 IgLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Supply& Infection 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: 2y0z 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 Watcr Resources Revised 2-22-2016