GW1-2021-07343_Well Construction - GW1_20210921

Print F,or NINE
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4448A tD
,�1
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-cased`wells OR LINER if a licable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft. 14f(eI'L 6 5/8 In, .188 G.STEEL
,-` 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: '4 U T 3 l3�EL�iz o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C 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
Agricultural ®)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) toResidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO PJATERIA,L EMPLACE XNT METHOD&AMOUNT
�
Non-Water Supply Well: 0 tt.
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Rcmcdiation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer.Test []StormwaterDrainage
Experimental Technology OSubsidence Control
_I Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additioniil sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc.)
Geothermal(Heating/Cooling Return) _ other(explain under#21 Remarks) ft. Q ft.
4.Date Well(s)Completed: v r z' Well ID# ft. ft.
5a.Well Location:
(' �kdneS
i ft. ft
Facility/Own&Name Facility ID#(if applicable)
587 8 ,�� mood "ZT.
Physical Address,City,and Zip ft. ft, -0\9
In Lao
p 0',Y I_11 21.REMARKS
r O "
County Parcel Identificationn No.(PIN) \0131 oR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one'lat/long is sufficient) 22.Certificati
s�s�: 2' N _7p°a4. `7c ' W Z1
6.Is(are)the well(s)oPermanent or []Temporary a ure ofCcrtificd Well Contractor Date
By signing this form, 1 herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 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 1 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: /C_/ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exanrple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 29 (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 Injection 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&Injection 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: completion of well construction to'the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016