GW1-2021-05926_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A
ft. ft. f S3 `3 188 0 ft. ft. LlOU y b+11 -f 2$'^�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wens)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 1 in. PVC
Company Name
'.` �t 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: tx 1 b� W�H ■y/L — V 7 q 1�� 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
I Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f[ ft in.
1 Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_ I Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 rt PORT.CEMENT POUR
Monitoring 13 Recovery
Injection Well:
I Aquifer Recharge rliGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test _ Stonnwater Drainage
Experimental Technology OI Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FRO 1110 ft.
(color,hardness,soil/rock e, rain sim,etc.)
ft. �
( M 1
4.Date Well(s)Completed: t0"`+ Well ID# //-O ft. W ft.
Sa.Well Location:
rA_ 0a V
Facility/Owner Name Facility ID#(Cif applicable)
ft. ft.
to!go a L i S AllwOv. 1✓le- �0✓tom /✓A1A 1 T ft. ft. (,
Physical Address,City,and Zip ft. ft.
l y.x;��'A 21.REMARKS
County Parcel Identification No.(PIN)
\nfol \,NR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 'UDC 'Z(
6.Is(are)the well(s)0 Permanent or 13Temporary Signatur fCcrlif ontractor Date
By, gnin s form, I hereby certify-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or ONo uh 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 y 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Totall well depth below land surface: ?0 (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 2@100') construction to the following:
10.Static water level below top of casing: 37 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
1I.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) / 7 Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitlone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: )V 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 Water Resources Revised 2-22-2016