GW1-2021-07354_Well Construction - GW1_20210921

Print Form ���i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
4448A to ���
C� ft. ft.
NC Well Contractor Certification Number Q I+ �t�oq
CUMMINGS DEVELOPMENTS, INC t'��G G��pn FROMUTER CASING DIAMETER I T ING(form ells ICKNESS NER if a Ir MATERIAL
+1 ft. ft. 6 5/8 : in. .188 G.STEEL
Company Name �("jO1 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: vP 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. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O "' _W ft. �/�
Monitoring []Recovery ft. ft. '-��^-
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stomlwater Drainage
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sim,etc.)
ft. QVV 0 ft.
4.Date Well(s)Completed: V-2 Well ID#
5a.WeH Location:
��
Facility/O
,w
/ner Name Facility ID#(if applicable)) ft. ft.
1yr'1_ N('- 14 W O 0 SI "_)D u416Lm � / /r�f 3 ft. ft.
Pbsical Address,City,and Zip 1Jft. ft.
k&JU
nn O/ 1?5 21.REMARKS
County 't / Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one lat/lon¢is sufficient) 22.Certification
35c, S�Lild N �$QS7• Z3 (vt W
6.Is(are)the well(s)oPermanent or []Temporary ignaturc ell 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: []Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction infornnation and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of dds 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 0 G SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'aand 2@100') construction to the following:
10.Static water level below top of casing: ✓5 (ft.) Division of Water Resources,Information Processing Unit,
I(water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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) bXV Method of test: t/ 24c.For Water Supply&Iniection 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: lfl�DL' 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