GW1-2021-07391_Well Construction - GW1_20210921

1,
Print 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 rL fr' 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR{LINERI if a licable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name }I ft. 9 Q ft. to-6 8 in. . 18t7 LeG
L' '1
16.INNER CASING OR TUBING 'eothermal closed-loop" T
2.Well Construction Permit#: H 54'1 W GIN Z O 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' B' 1°'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [Wesidential Water Supply(single.) ft ft in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT .
_ lrrl ation FROM TO WTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O R. ,h ft. o ,, '
__I Monitoring ®Recovery ft. �" ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a lieable
Aquifer Storage and Recovery ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft ft.
Experimental Technology Subsidence Control
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 e, rain size,etc.)
rt. (03 ft. V 1
4.Date Well(s)Completed: -10'Z-( Well ID# ft. 4 ft. lal kd
5a.Well Location: $ ft. 2.4C tt.
55E-rnA Holder ft. ft
Facility/Ownc me Facility ID#(if applicable)
ft. ft.
1491 JeUeics Cross 2d ,iju68%6, 2.1an ft.
P��hysiicaal Adddrresss,��City,and Zip ft. ft.
!i'1LAtl/1f�rw� 8ag910 la$73 21.REMARKS g5 UY�\c
County Parcel identification No.(PIN) GO
ptOG o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiff/wcll field,one
ellat//llong is sufficient) 22.Certificatio
-Ib -zl
6.Is(are)the well(s)oPermanent or Temporary Si turc o Well C tractor to
B 'ning this farm.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ONo 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: a (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Ca 200'anfd 2Q100') 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
I I.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 SUPPLYuWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l 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: L.4 aL completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016