GW1-2021-07382_Well Construction - GW1_20210921

Prfint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A r
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased, ells OR LINE
R If S Iicable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER 1'HICK,NESS MATERIAL
+1 ft. 2 ft. 6 5/8 in. .188 G.STEEL
Company Name
rr__p O '`_ Z 16.INNER CASINGOR TUBING eothertbal,closed-too
2.Well Construction Permit#: 48 to W 4F LN I FROM 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. fL in.
_.i Geothermal(Heating/Cooling Supply) PResidential Water Supply(single.) ft. ft. in
Industrial/Commercial 13Residential Water Supply(shared) .18.GROUT
Irrigation FROM TO n4TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Ln ft. 4`�� ��, d
Monitoring 13Recovery
Injection Well:
fr. ft.
Aquifer Recharge 13Groundwater Remediation
19:SAND/GRAVEL.PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain tinder#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rocke, rain size,eh.)
tt. d ft. (Vol/
4.Date Well(s)Completed:�r��z Well 1D# Sj tt. v ft.
5a.Well Location:
^ n
Facility//OwnerN/a�me T Facility ID#(if applicable) ft. ft. tit
l__r'LS mA& 'LN . ft. ft. P V
Physical Address,City,and Zip c pp 2 ft. ft. ptQGe
&hACLnLR— 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onnee�lat/long is sufficient) L� �a I
l�A 22.Certificatio
' 0 ��•"1'j '� 1 N � 10 ZZ 1 W yQ —z 1
6.Is(are)the well(s)oPermanent or [ Temporary Si Certified Well Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or MNo with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repairs 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: !/040 (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'mid 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
ffwater 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
v�
13a.Yield(gpm) e=00 Method of test: /% 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: ` a y 7- 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