GW1-2021-07344_Well Construction - GW1_20210921

Print Form,
WELL CONSTRUCTION RECORD (GW-l) For internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name
FROM .110 DESCRIPTION
ft. ft. '
4448A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS, INC FROM I TO I DIAMETER I THICKNESS MATERIAL
+1 ft. U U ft. 6 5/8 in. .188 G.STEEL
Company Name _1
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 4 a 3 W E LN 2 i FROM TO DIAMETER I 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSI-LE THICKNESS MATERIAL.
I Agricultural ®Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) Pkesidential Water Supply(single) tt. fr. in.
IndustriaUCommercial EIResidential Water Supply(shared) 18.GROUT
Irri ation FROM nTO� MATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: Q ft. !J� ft. WAII- O.J_
Monitoring 1311ecovery
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FR TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage
Experimental Technology Subsidence Control
_I Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DF SCR TION(color,hardness,soil/rock e, rain size,etc.)
Q ft. 014 ft. 6 11
- of
4.Date Well(s)Completed: ` Wel1ID# .02 42f1. f �(
Ct. ft.
i5a.Well Location:
{A_
kky;0 u �lUJ1ZR I�1 /J IItT r ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1
5751 Lat�lri �'��dn�' S�Cla (� P7341 e. ft. 4y 'rat
�Physical Address,City,and Zip T ft. ft. nCQGQ.
21.REMARKS .$
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i''ff�we/ll field,one Iat/Along i1sufficient) a / / gq 1 22.Certification:
N 1 n �10• IsOI W -q-Z
6.Is(are)the well(s)o Permanent or OTemporary turc o ified Well Contractor Date
y signing this form,I herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONo with 15A 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 copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back q(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 l 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: /�Q ' -) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(exaniple-3@200'and 2@100') construction to the following:I
10.Static water level below top of casing: q (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) 13 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: l y� d 7 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