GW1-2021-05980_Well Construction - GW1_20211025

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ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONE
Well Contractor Name FROM TO I DEscgLrriON
ft. ft.
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Cummings Developments, Isle FROM TO DIAMETER THICKNESS MATERIAL
.1 ft- Ilf ft. 6 in. PVC
Company Name
"-�1 Q 16.INNER C SING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: Loa 1'' OI FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UICi 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 QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E§Residential Water Supply(single) ft. ft. in.
i lndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
!lrri ation FROM TO MATERIAL EMPLAC ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. +
Monitoring ElRecovery ft. ft.
Injection Well:
fr. fr.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonrlwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
1 49 ft. 22 ft. Sal;/
4.Date Well(s)Completed:10 +I -Z I well ID# 22 ft- g140 I-
5a.Well Location:
+
Facility/Owner Naw3l Facility ID#(if applicable)a;751�
DAM D(on g.- Carte f7d C'�r qW Ih11
Physical Address,City,and Zip I ft. ft.
Qrc --c,� 9 t��}c►o9 TrI
21.REMARKS
County Parcel Identification No.(PIN)
[OOeyS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long it sufficient) 1 22.Certificatio000,
ISO 51.032 N1�° 11•e�� W -�
6.Is(are)the well(s)oPermanent or 131remporary ignatur err ell Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or FINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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: 9 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'aannd 2@100') construction to the following:
10.Static water level below top of casing: I 1 (ft.) Division of Water Resources,Information Processing Unit,
/fwater 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
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 JELLS ONLY: 1636 Mail.Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Ab' 1?04u-I 24c.For Water Supply&Iniection 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: /t7 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