GW1-2021-05791_Well Construction - GW1_20211025

PrinfForm` �'
' 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 ft. ft. dl IL y
ft. ft. 4 sIy
NC Well Contractor Certification Number INC15.OUTER CASING{for multi-eased wells OR LINGER if a licable
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER THICKNESS MATERIAL
ft ft. ft. 6 5/8 in. .188 G.STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed400pj
2.Well Construction Permit#: 41t V L1 goo-z-1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. it in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
_ Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in:
Indushial/Commercial Residential Water Supply(shared) 18.GROUT
I hTI ation FROM TO MATERIAL EMPLAC ENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft.
:)Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL'PACK if a lif' able,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mther(explain under#21 Remarks) FROM TO DESCRIPTION(coloq hardness,soiurocl type,grain size,etc.)
® ft. ft.
4.Date Well(s)Completed: '2)`Z Well ID# 7$ft- Z(Oa ft G.
5a.Well Location:
ft. ft.
yi rainia `Th
FacilityPaner Name I Facility 1D#(if applicable)
Kr - t3.1ot17 ft. rt. 2�2
Physical Address,City,and Zip ft. ft.
`� 21.REMARKSA nar`/' O®ViY1R @C
County Parcel No.(PIN)5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflon is sufficient) 22.Certification:
3L°/L sox N I 9 v 7,S- 711 W
6.Is(are)the well(s)0 Permanent or 13Temporary Signal ofC ' ed Well Contractor Date
By signing this form,I herebv certify that the well(s) was(were)constructed in accordance
7.is this a repair to an existing well: DYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 additionai`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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1z It�_' (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 r@i 200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
tfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i1.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
A D
13a.Yield(gpm) ` ""- Method of test: *41", F 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: 91(2raz 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