GW1-2021-04185_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
>1.Well,,Contractor Intormation:
Christopher Cummings 14.WATER ZONES
Well'CoatractorName FROM TO DESCRIPTION
� ft. rt.
3170A �
ft ft. r
NC Well Contractor Certification Number 1.5.OUTER CASING.for multi cased wells OR LINER if a liable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. '� tt. 6 5/8 in. .188 Galv Steel
q 16.INNER CASING OR TUBING l eothermaclosed-loo
2.Well Construction Permit#: U Z® ®Z d FROM TO DIAMETER THICKNESS MATERIAL
/.ist all applicable well conctnicliat permits(Le.i/IC',('oanty,Stale, {rariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i 17;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. fa in.i
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) fr. ft. in.
1ndustrial/Commercia 13Residential Water Supply(shared)
48..GROUT
711irrip,ation .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 ft. Port Cement Pour
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge r3Groundwater Remediation tt ft.
19:=SAND/GRAVEL.PACK flfapplicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO IMATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. fr.
Geothermal(Closed Loop) OTracer 20.'DRILLING:LOG attach additional,sheits if'necessa
Geothermal(Heating/tooling Return) . Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiUrock type,gnin size,eta
Z° "
6 ft. )'), ft. LS )
4.Date Well(s)Completed: ( z� Well 1D# 2 2 ft. 6 ft. ui
5a.Well Location: ft. ft.
m U+0 fa ft.
Facility/Owgii Name, Facility ID#(if applicable) ft. ft. R, g„
1 �.�/Loo 1�1otL�4 �, a2d Chan.1 1fi�11 2?51�. ft. ft.
Physical Address,City,and'Zip g p_p2 ft. ft.
2021
�••�r"AaA .3
� 9��O 1O Z1p 1 21:REMARKS
si�
County Parcel Identification No.(PIN) I ing Unit
., •• ���i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: [)N ` SCT'R On
(if well field;one latAong is sufficient)
—•y� 22.Certificatio
`3S" t5.`ll to N /-1,�0-7-
6.Is(are)the well(s)SPermanent or E3Temporary I_V
ofCerti Contractor Date
7
g t rm,I hereby certify thatthe wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or xMNo CAC 02C.0100 or 15A NCACO2C.0200 Well ConstntctionStandards and that a
/jthlr is a repair,frlf orrl/mown well constncetion information and explain the nature of this record has beenprovided to the well owner.
repair under#21 remarkssection or on the back ofthisform.
. ediagram 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 drays of completion of well
Fa nudl/ple wells list a/1 depths if d/Qerent(example-3 t,20 'and 2@/00') construction to the following:
10.Static water level below top of casing: :(ft.) Division of Water Resources,-information Processing Unit,
Ijwater level is above casink rrse
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:;6 24b.For Infection Weiss: In addition to sending the form to the address in 24a
12.Well construction method: Rolary above, also submit one copy of this form within 30 days of completion of well
i.e.auger,rot construction to the following:
( g rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)' Method of test: Air Rotary 24c.For Water SuoDly&injection Wells: In addition to sending the form to
1HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:; Amount: 32 a z completion of well construction to the 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