GW1-2021-07368_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name n FROM TO DESCRIPTION
15.1
4448A Q 1 ,
zgq
ft. ft.
NC Well Contractor Certification Number
pCO r`O� 15.OUTER CASING(for mulfi cased wells OR LINER if a licable
Cummir)gs Developments, Inc 3�%O cog. " FROM TO DIAMETER THICKNESS MATE AL
_tr( A +1 ft. ft- 6 in. Q ��
Company Name
16.INNER CASING OR TUBING etithermal closed-too
2.Well Construction Permit#: WZ.! - FROM TO DIAMETER THICKNESS MATERIAL
List al)applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3iwi ell Use(check well use): ft. ft. in.
(.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]MunicipaUPublic ft. ft. in..
_'Geothermal(Heating/Cooling Supply) gI Residential Water Supply(single) ff ft in.
_-1 Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO ATERIAL -EMPLACE r
ENT METHOD&AMOUNT
Non-Water Supply Well:
I
Monitoring ©Recovery
Injection Well:
ft. ft.
Aquifer Recharge Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O)Stormwater Drainage fa ft.
Experimental Technology [ Subsidence Control ft. ft.
_J Geothermal(Closed Loop)' Tracer 20.DRILLING LOG attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. 3 fl. 1
4.Date Well(s)Completed: -�—?-I Well 1D# ft. 4 0 ft.
[t. �• ft.
Sa.Well Location:
It.
,TD� O"'AW;I&Y S
Facility/Owner Name Facility ID#(if applicable) h• ft.
au
2$34 L -y Nll �aYP� 7r. 1116erou-&-
Physical
Address,City,and Zip IL ft.
9 92611 71oZ'i 21.REMARKS
County Parcel Identification NO.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is surcient) 6 f 22.Certification-
3-
6.Is(are)the well(s)o Permanent or 13Temporary SignP6 ofC c c Contractor ! Date .;
ring this form,I hereby certify that the well(s)was(were)constructed in accordance-
7.Is this a repair to an existing well: Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 1 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: �a0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion'of well
For multiple wells list all depths)fdii ferent(example-3@200'and 2Q@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: 6 (in.) 246.For Infection 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
the address(es) above, also submit one copy of this form within 30(days'cif
13b.Disinfection type: HTH Amount: 20sL completion of well construction to the county health department o0the`county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources+ Revised 2-22-2016