GW1-2021-07367_Well Construction - GW1_20210921

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher':Watcher g� ;14.WATER'ZOA'ES _
Well Connector Name p�,¢`� FROM TO DESCRIPTION
ft.444$A ft- �,QCf
&s '�1
ly 1 ft. fr.
NC Well Contractor Certification Number C Q D b
�L.t � EFROM
TER,CASIRG(for ttSvitt-casedawelts t1R LINER ifit�Iicable
Cummings Developments, inc (Cr'p'u' (1tJ TU DIAMETER THICKNESS MATERIAL
ft �/ ft. sCompanyName {O((.• �N� !ERt t15INGORBING.(`eotherra -closed liid2.Well Construction Permit#: -II► 7-1 -+ PJ0 1 TO DIAMETER I THICKNESS MATERIAL
List all applicable well constructionperntits fl.e.WC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: `17.SCREEN)
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. fr. in.
:)Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft,
_ IndustriaUCommercial Residential Water Supply
PP Y E_18 GROUT` -- — _:_
- ! hri ation FROM TO -TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- -o ft. a tt
:IlMonitoring _)Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:,SAND/GRAVEL PACK if a lieable _:.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStorllwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer :20.DRILLINGaO;Gi attacli`addiaonal'isleeetsaf necessa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks FROM To DESCRIPTION Icolor,hardness,solUrock type,gmin AM etc.)
ft. fL i
4.Date Well(s)Completed: 11-7-1 Weil ID#
5a.Well Location: fr. ft.
_rCII& . tap-rs ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
339 r-wx Kit rria rn r A1561jx"aAL727 it. ft.
Physical Address,City,and Zip ft. ft.
- _ gas _!98,9
2] REMARKSR _ _
County' i� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fiend,,one lot/long is sufficient) p 22.Certificati
.36"ofa•S�gt N 77 03 -��d W
-ZI~-Zl
6.Is(are)the well(s)OPermanent or Temporary at etrifled Well Contractor Date
y signing this form,1 het ce�tJfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or MNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
{'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 at the back of this form.
23.Site diagram or additional weti,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: (ft.) 24a.&L A11 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and2@100') construction to the following:
10.Static water level below top of casing: 3'l1 (ft.) Division of Water Resources,Information Processing Unit,
If 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l3a•Yield(gpm) t/ Method of test: I/ 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. !�'Z completion of well construction to the county health department of the county
.,' where constructed.
r• r
Form GW-I Notth Carolina Department of Environmental Quality f Divisio"n of Water Resources Revised 2-22-2016