GW1-2021-07359_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: y, p
Christopher Watcher "XIN 14.WATER ZONES
Well Contractor Name Irv, k FROM TO DESCRIPTION
J��� ft. ft. � �;
4448A Q �� eyy�t�� ft. ft.
NC Well Contractor Certification Number �� �QG �Q�
Cummings Developments, IncQ(��oj2G� FR MUTER CASING form Llti-casedDIAMETEReIIs OT ICKNENERSS a IrMif ATERIAL
+1 ft. '1 ft' 6 in. PVC
Company Name 4Q
` 16.INNER CASING OR TUBING ebthermal closed-loop)
2.Well Construction Permit#: 21 LAN N H Q•0 34�1 FROM I 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. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
1 Agricultural [3Municipal/Public ft. ft. in.l
_ Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) ft. fr. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEKFNT METHOD&AMOUNT
Non-Water Supply Well: 0 R. ZO
:)Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM it 101 TO ft. DESCRIPTION(color,hardness,sonfrock type,grain sirx,etc.)
I
4.Date Well(s)Completed:_ Well ID#
5a.Well Location:
9 UID V% . it
Facility/Owner Whe Facility ID#(if applicable)
a�313 ft. rt.
4 YDO 1-6dl.n 1Dr. '1 6_A!..k �7ord
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long i sufficient) 22.Certificatio
35°Si. 335N 7Q°cf�� Gt w
6.Is(are)the well(s)0 Permanent or 13Temporary a ofCcrtified 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: E]Yes or 15No 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 information and explain the nature of[he copy ofthis record has been provided to the well owner.
repair under#21 remarks section or an 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: Lo (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdiQerent(example-3@200'aandd2@100') construction to the following:
10.Static water level below top of casing: y 1 (ft.) Division of Water Resources,Information Processing Unit,
{!water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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.) o
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
�) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount:�l/rDZ completion of well construction to the county health department of the county
where constructed. E
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016