GW1-2021-04191_Well Construction - GW1_20210401

'WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor information:
Christopher Cummings I 14;WATER;ZONES"
- Well Contractor actor Name TO I DESCRIPTION
3170A ft. ft. Xvp
ft. ft. j
NC Well Contractor Certification Number
I&OUTER.CASING for multi-cased.Wells ORLINER'if:a licable
Cummings Developments, Inc. FROM O DIAMETER THICKNESS I MATERIAL
Company Name +1 fL tr. 6 5/8 10• .188 Gab Steel
16:INN ER.CASING.ORTUBING "eothermal'closed=loo -
2.Well'Constructil c Permit#: © O I. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit.,;(i.e.t/1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
[te Supply Well: 17.SCREEN_
icultural �Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS i MATERIAL
thermal(Heating/Cooling Supply) ft. fL in.
g pp Y) QResidential Water Supply(single)
strial/Commercial ft ft. in.
Residential Water Supply(shared)
ation18:GROUT
ater Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
itoring 0 ft. 20 ft. Port!Cement Pour
Recovery % ft.
on Well:fer Recharge Groundwater Remediation ft.
fer Storage and Recovery Salinity Barrier 19:SAND/GRAVEL PACK.ifa 'livable -:fer Test FROMTO MATERIAL EMPLACEMENT METHOD
Stormwater Drainage ft. ft.
rimenfL
tal Technology Subsidence Control ftermal(Closed Loop) Tracer
20.DRILLING LOG attach additional sheets
ermal(Heatin Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION color hardn soiUrock rain e' etc
,® ft. ft.
bt
4.Date Well(s)Completed: Well ID# .
ra 01
52.Well�Location: fr, ft.
1 ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Ifl 1�1 bcA E rn5 �a�n 1�, ft. ft. Nk X
Physical Address,City,and Zip fL ft. ryV iZll
C.unI�8 KJ 310 3 21.REMARKS Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient)
2s� •7. � �..,� 22.Certiric� /�
do 9 N 74 m L 3• �� W
6.Is(are)the well(s)OjX Permanent or oTemporary atu Certified Well Contractor ,
Date
7.Is this a repair to an existing well: Oves or No withigning this 15A NC ACf02C.0100 or ISA NCAC rm,I hereby certify t 02C.0200 the s)Well Consinteedon slandatrds and thaat a
if this is a repair.Jill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under i111 reinarks.section or on the hack of this form.
23.Site diagram or additional well details:
8.For GeoprobetDPT 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
y��9.Total well depth below land surface: / SUBMITTAL-INSTRUCTIONS
(ft.)Far miduple wel/s dsi all depths ifdi,(fereni(exannple-3Q200'and 2@1001) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
/fwater level is above casin&use 11, (ft•) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
12.Well construction method: Rotary 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) r Method of test: Air Rotary 24c. For Water SuDDI. &In' cti�n Wells: In addition to sending the form to
13b.Disinfection type: HTH the address(es) above, also submit! one copy of this form within 30 days of
Amount: ��d 2 completion of well construction to Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016