GW1-2021-07369_Well Construction - GW1_20210921

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:YELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher ��� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�+�f�4448A � � A
�01 <r.V
P
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased' 11s)OR LINER if a lieable
Cummings Developments, Inc ��CQQeu. FROM TO DIAMETER THICKNESS MATERIAL
�irt ta�i11
J +t ft. ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: �O(� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Tariance,etc) ft. ft. in.
3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSILE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in..
_)Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.'
_j Industrial/Commercial 13Residential Water Supply(shared) IS.GROUT
Irri ation FROM TO MATERIAL EMPLAC ENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 7
0 ft. O
Monitoring 13 Recovery
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control fL tt.
_Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sim,etc.)
ft. j�a ft.
4.Date Well(s)Completed: 1A-7-1 Well ID# & ft.
5a.Well Location:
a. L\\--
I I a A M of d%+\\
Facility/OwncrName Facility 1D#(ifapplicable) ft. ft.
Ph sical Address,City, ip
9 7 5 1 3 (D 21.REMARKS
County 9 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long f js sufficient) 22.Certification:
?2ss,,Z-7 N W P
6.Is(are)the well(s)oPermanent or 13Temporary aturc of rc well Contractor Date
Wing this form,I herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 pagejto 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: 2 SO A) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2@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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.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
�j 13a.Yield(gpm) / / Method of test: r14e 24c.For Water Supply&Infection 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: 2 9d Z 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