GW1-2021-07364_Well Construction - GW1_20210921

Print Formt.1";Y
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: �w�
Christopher Watcher 14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
�O
4448A �
�e�,s�n�
NC Well Contractor Certification Number ��(0'
c � -15.OUTER CASING for multi-casedlwells OR LINER ifa licable
Cummings Developments, Inc tr`3�r0 `�eJ FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft 6 in. PVC
Company Name
N '16.INNER CASING'OR-TUBING eothermal closed-loop) -
2.Well Construction Permit#: W 2I t)0 31. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
b'ROM TO DIAMETER. SLOTSI"LE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. fr. in'
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fr. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO TERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: 0fr.
Monitoring 13Rccovery 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 [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
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 size,etc.)
8 ft. p ft. S0,11
4.Date Well(s)Completed: 1 Well ID# fr. fr. n�l`�1,
5a.Well Location: 'Z ft. r o ft.
n
l Q t SC)tl S 1LA OL 14 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
tat# rco_ Olir c, lFy{,y s+ 2d. C1,&.pe.l [KII -17s)y ft. ft.
Physical Address,City,and Zip ft. ft.r1.1 Ya� Q 1 ft�(0 !n
1 ` -]0 7 q 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longg is sufficient) 22.Certificatio
3s*5a. q5 / N 110 61 1^I7 b, W _
6.Is(are)the well(s)�Permanent or Temporary �hgnmg
rr' ell Contractor Date
form,i herebv certify-that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis it 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 3(3 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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
{fwater level is above casing,use•'+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: in addi i tion 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) 2 Method of test: 24c.For Water Supply&Iniectil n 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: OZ 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