GW1-2021-05789_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A
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 +1 ft. ft. 6 5/8 : in. .188 G.STEEL
16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: HI Q'3 W C LN 2 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) 18Residential Water Supply(single.) tt. ft. in:
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stonnwater Drainage
Experimental Technology nj Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 6ROM I TO DESCRIP' N(color,hardness,soil/rock type,grain size,etc.)
ft. ft. - 0�
4.Date Well(s)Completed: Well ED# ft. 2 J o ft.
5a.Well Location:
�Md?�Y11A -.�t�lf� Eltf�Ks, ft. ft.
Facility/Owner4amC Facility ID#(if applicable)
3-1cis 'ShCV'y\-0_Ne.'-6r. 11'fta,wn'QJ-A I rt. rt. U it
ssm9
Physical Address,City,and Zip ft. ZIP eC�;on
1;3S3`q 21.REMARKS 1
County Parcel Identification No.(`PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lat/lon�g is sufficient) -7 22.Certification:
�v/' N l 0 1S "1 3 W
6.Is(are)the well(s)o Permanent or OTemporary S' turc of Certifi ontractor Date o�
ping this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or IoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction inforniation and explain the nature of1he 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �j0
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 Z 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
HTH
2��� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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