GW1-2021-05795_Well Construction - GW1_20211025

Print Form_ '.
WEi L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
CHRISTOPHER WATCHER 14.WATER ZONES
FROM 'I'O DESCRIPTION
WcllContractorNante ft. ft.
4448A NC Well Contractor Certification Number ft. ft. 1 I
15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 2 ft. 1 6 5/8 In' 188 G.STEEL
/n�Q 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: 1 LI W*&LNZ 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,Slate, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
:]Geothermal(Heating/cooling Supply) Residential Water Supply(single) ft. ft. in.
_I Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_]Irrigation ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge r.11 Groundwater Rcmediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,efc.l
Geothermal(Heating/Cooling Return) _l Other(explain under#21 Remarks) ft. ft. /
4.Date Well(s)Completed: J ( Well ID# ft. / Q ft.
Sa.Well Location:
ft. ft.
ft. ft.
rn L (,O;Ihu.rn
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
IV ?6
Physical Address,City,and Zip
f[. ft. processing Unit
"I kb Q to 173 a►�of 21.REMARKS n
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long ilsufficicnt) 22.Certification:3ull 333 N �1° 1q•a�9 ' W
6.Is(are)the well(s) Permanent or Temporary atur crtificd ell Contra c or Date
y signing this form,1 herebv certify than the well(,) was(were)constructed in accordance
7.is this a repair to an existing well: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthir it a repair,fill out known well construction informalion and explain the nature a/the copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this jornn.
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-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: v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijd Brent(example-3@200'and����2@100') construction to the following:
10.Static water level below top of casing: �'Cr,//O (ft.) Division of Water Resources,Information Processing Unit,
1(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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
.e.auger,(�r ,g rotary,cable,direct push,etc.) construction to the following:
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: AIR ROTARY 24c.For Water Supply&Iniectionl Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: HTH Amount: 47-oZ 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