GW1-2021-07355_Well Construction - GW1_20210921

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'WELL CONSTRUCTION RECORD (GW-1) I For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM 4448A TO DESCRI 'ION
ft. ft. . /
��,�
``�, ft. ft.
NC Well Contractor Certification Number S �J 15.OUTER CASING(for multi-cased±ells)OR LINER if a licable
Cummings Developments, Inc "� t0�'P'�y FROM TO DIAMETER THICKNESS MATERIAL
"_.. \O +1 ft ! ft. 6 in. PVC
Company Name �`t �� G 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Vol
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): It. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO XATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10
ft. TO ft. �
,_ Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery EJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control
J Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additionlal sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remazks) FROM TO DESCRIPTION(color,hardness,soiVrock type,gnin size,etc.)
© ft. 26 ft. G 17
4.Date Well(s)Completed: ��C. Z Well ID# 26 ft. 2A ft. A
5aa.. on
Well Location:
1 ft. ft.
oyi g �' V 1 IQ S tie
Facility/OJner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
0-h9 a m n-4 g o 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/l(on�gisis sufficient) a 22.Certification:
6.Is(are)the well(s)oPermanent or Temporary ' at crti ed Well Contractor Date
By'signing this form,I herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or Mi No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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 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 I 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: 92,0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service C f enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) r 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&Iniection Wells: In addition to sending the form to
.�,q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: YL 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