GW1-2021-05979_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD(GW 1) Print Form
For Internal Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER
14 WATER•ZONES"
Well Con ractor Namc FROM TO DESCRIPTION
4448A ft. ft. $11),
NC Well Contractor Certification Number ft., ft. 4 fly
CUMMINGS DEVELOPMENTS , INC 15.
MUTER:CT�ING(for in D AMETEwells OR INER'i a If ible) AL
Company Name +1 ft ft• 6 5/8 In. 188 G.STEEL
O.y ® 16.,INNER=CASING OR TUBING'" `eothermal closed-loo
2.Well Construction Permit#:_ i -- p( RROM TO DIAMETER THICKNESS MATERIAL
LislaUuppliruble well rwhstructionpermits(i.e.U1C,Cohnhty.State,I�ariance.etc.) in.
3.Well Use(check well use):
ft. ft. in.
Water supply Well: 17.SCREEN'
Agricultural F'ttOM TO DIAMETER SLOTSILE 'rnICKNESS MA'fER1A11
oMunicipaUPublic ft. ft. jo.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single)
IndustriaUCommercial ft• ft. in.
Residential Water Supply(shared)
Irci ation 1S..GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
a ft• 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Injection Well: ft• ft.
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licalile) i
To
Aquifer Test FROM
oStormwater Drainage MATERIAL EMPLACEMENT METHOD
f[. g,
Experimental Technology QSubsidence Control
ft, ft.
Geothermal(Closed Loop) Tracer
20:DRILL'ING`LOG'attach.addttlonalsheets if necessa ).
Geothermal(Heatin Coolin Retum) DOther(explain under#21 Remarks) FROM TO DES PTION icolor,hardness,soiltrock type. rain size,etc.)
ft. / ft.
4.Date Well(s)Completed: '( 21 Well ID# /S/ ft. ft.
Sa.Well jLocation:
ft. ft.
Facility/Owner Name 1� Facility 1D#(ifapplicable) ft. ft.
�Y-1YL1�_1"iZl�v� �27 Q
Physical Address,City,and Zip ft.
8�`. •-7/n D
21.REMARKS
O�
County Parccl Identification No.(PIN)
Qce�sing
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In �R SeCxlO
(if well field,one]at/long is sufficient)
3/O o^' u� / 22.Certifica
10 �( q N 7?0 JZ.413 W
6.Is(are)the well(s)OPermanent or oTemporary ignat Cc ild Well Contractor
Date
7.Is this a repair to an existing well: BY signing this jornh./herebv certify that the wells)was(were)constructed in accordance
\" l this is a repair.fill out known wellgconsinictioni formation tu�N�ain the nature of the with
1PY ajth��eco d haAC sh been provided to the tt It ow 0 Well Construction Standards and Ueal a
f P f p cn
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1�/%f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ jl./
For multiple wells list all depths ifdifferent(erample-3@200'and 2@100") 00 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Ifwater•leve!is shove casing use Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
"+"
il.Borehole diameter: 6 (in.)
1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection 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 of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) / 1636 Mail Service Center,Raleigh,NC 27699-1636
Methgd of test: AIR ROTARY 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
13b.Disinfection type: HTH the address(es) above, also submit one copy of this form within 30 days of
Amount: e'lZ 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