GW1-2021-05802_Well Construction - GW1_20211025

P,�int Form
" IVELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPT ON
4448A
ft. ft.
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , C FROM TO DIAMETER THICKNESS MATERIAL
+1 rLtj 00 f' 65/8 In' 1 .188 G.STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 14 R 30 L,,)E L tN 7 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.
Water Supply Well: 17.SCREEN
FROM to DIAMETER SLOTSIZE THICKNESS MATERIAL
'IlAgricultural Municipal/Public ft. ft. in.
-I Geothermal(Heating/Cooling Supply) alkesidential Water Supply(single) ft. ft. in.''
_1 Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft PORT.CEMENT POUR
Monitoring 13 Recovery
Injection Well:
ft. ft.
i Aquifer Recharge Groundwater Rcmcdiation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
Experimental Technology Subsidence Control
—I Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _.Other(explain under#21 Remarks) FROM TO DESCRivriON lcolor,hardness,soil/rock type,grain size,etc.)
ft.ft. 11 ` ` '
4.Date Well(s)Completed: l/ ( Well ID# ft. ®rL
Sa.Well Location:
tt. ft.
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft.3Lo k 9 tO c Sal Nw�'1 -It k C_w� ft.
reSSW119 UPI
Physical Address,City,and Zip ft. ft. In
form3t1011 PrO
4k -L ro as 3 1 1j 7 Z 21.REMARKS rX
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22.Certific
7`6 v 0-*' -7 1 1 N T�� �Q' �/ W
Lo di
6.Is(are)the well(s)oPermanent or 13Temporary Signature of icd Well Contractor Date
signing this form,l herebv certify that the well(s)was(were,)constructed in accordance
7.Is this a repair to an existing well: 13Yes or E)No 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 o(this forn.
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: �O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(exannple-3@200'and 2 a/00') construction to the following:
10.Static water level below top of casing: l (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,rise"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Infection 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
(i.e.auger,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 SUDDIy&Infection 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: .3,7OL 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
t