GW1-2021-07383_Well Construction - GW1_20210921

.Print Form;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infarmatiitn:
Christopher Watcher 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4448A ft. ft. • "b WO
NC Well Contractor Certification Number { 15;OUTER CASING(for multi-eased*all$ OR LINER if a"'lieatite .
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft $ in. 8 8 5�
Company Name
16.INNER CASING OR TUBING--(geothermal closed=lo
2.Well Construction Permit#:', 31 i W E f-1.2,ti FROM za DIAMETER THICKNESS r' MATERIAL
List all applicable well construction rernnits(i.e.U1C,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ; ft. ft. in.
Water Su I Well: 17:SCREEN '
pp y FROM TO DIAMETER SLOT SIZE THICKNESS 5ATERIAL
Agricultural ®Municipal/Pubiic ft. ft. in.
Geothermal(Heating/Coolmg Supply) JoResidential Water Supply(single) ft. ft. tn.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri tiOri FROM TO MATERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: Q 'T,V ft OO# der
Monitoring 13Recoveiy ft fL
Injection Well:
Aquifer Recharge OGroundwatcr Remediation 19.SAND/GRAVEL PACK if applicableY,
FROM TO Aquifer Storage and Recovery OSalinity Banier 5
MATERIAL EMPLACEMENT METHOD,
Aquifer Test E)Stonriwater Drainage ft. ft
Experimental Technology [3Subsidence Control M ft.
Geothermal(Closed Loop) 13Tlacer 20 DRiLLiNG LOG ettacb additionaksbcets if aecessa
Geothermal(Heatin Coolin Return) ElOther(explain under#21 Remarks) F?RO fL TO ft DESCRIPTION'(color.hardness,softtreek type,gmin size etc.)
4 4.J
AA q
4.Date Weli(s)Completed: Ir well I11# ft. q 't ft. w, '
So.Well Location: ft- n0 !I ��
C �Sh Y1 ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
;t QRlAtkLL
t��e8 ft, ft.
Physical Address,City,and Zip 0110
/�! a ft. ft.
(QGP'.
i 15 a (T lt�d 5 2t.REMARKS r
\10
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/> utes/seconds or decimal degrees:
(if well field one lattlong is sufficient) �� 22.Certification`
97e Sbl� d N (-!l®t'I• i W ���q' Z�
6.Is(are)the well(SOPermanent or OTemporary S° turo o Ied Tell Contractor Date
l y signing this form,1 herebv certify that the weills)was(were)constructed in accordance
7.Is this a repair to an existing well: 13.Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
if this is a repair,fill out known well consirtietion ilrfornhation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 rennarks section or on the back ofyhis fonn. 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 OW-i'is needed.'Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below iand'snrfac : <' (ft.) 24a. For All Wells: Submit this form within,30 days of completion of well
For nnaltple wribs list all depths(fdoerent texanip A-3Qa 200'and 201001 construction to the following:
g
10.Static water level below top of casing: ' Jb (ft.} Division of Water Resources,Information Processing Unit,
If water level is above casing,use"4-' 1 1617 Mail Service Center,Raleigh,NC 27699-1617
S
11.Borehole diameter: in.} 24b.For Iniection Wells: in addition to sending the form to the address in 24a
IL Well construction method: ry
(iota, above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) Meth d of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Oil F! i Amount: completion of well construction to the county health department of the county
i
where constructed.
Form OW-1 or h Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016