GW1-2021-05799_Well Construction - GW1_20211025

+'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: z
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A I 'I ft. Ilift. 5 1(09-170'
)1ST " rt.
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 .p1 ft. I I 9A ft. 6 5/8 in. .188 G.STEEL
u`1 ><i A� 16.INNER CASING OR TUBING(geothermal closed-loop)
9 1
2.Well Construction Permit#: � 1 tD 8 W V�'2A 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. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [Wesidential Water Supply(single)
I lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
_—]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
J Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge rlGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery EJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_)Aquifer Test [3Stonnwater Drainage
ft. ft.
Experimental Technology Oj Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain tinder#21 Remarks) FROM To DESCR ION(color,hardness,soil/rock e,grain size,etc.)
ft. 02 ft. 6;
4.Date Well(s)Completed:�_ Well ID# Jot.
ft. Q ft. 6
Sa.Well Location:
ft. ft.
rt. ft.
f
Fact ity/Owr N<n a Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip M ft. ft.
b g 5q 21.REMARKS PrIlrinssing
County Parcel Identificati (PIN) R S8CbO11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certificati
3�5� , 3-13 N ?R°aq _ 9�Y w D-J- a)
6.Is(are)the well(s)oPermanent or 13Temporary Signal e ' 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: 13Yes or EJNo 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 o/7his 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: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! F O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifafi ferent(exantple-3@200'and 2 cr 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 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /6VZ 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