GW1-2021-07392_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CH RI STOPH ER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� 1y
ft. ft.
4448A
ft. ft.
NC Well Contractor Certification Number
INC .15.OUTER CASING(for multi-cased wells' OR LINER if a Iicable
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER I THICKNESS MATERIAL
Company Name
+1 ft. ft' 6 5/8 in. .188 G.STEEL
yJ 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: J-lI5`I W ELN%g FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CountyState, variance,etc.) rt. ft. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
_ Geothermal(Heating/Cooling Supply) BaResidential Water Supply(single) ft. ft. in.
_i Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O H. zo
:Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation 19.SAND/GRAYEll PACK(if applicable)
,Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology Subsidence Control ft. rt.
Geothermal(Closed Loop) r3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sirs,etc)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ® ft. _% ft.
O �
4.Date Well(s)Completed: Z 1 Well ID# ft. Q ft. /
5a.Well Location:
ma,eta.t
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
24,q4 ML►.'6a,.a. �`'I�ll �d �rahnwt a7a53 rt. rt. p `
Physical Address,City,and Zip ft. ft. §S�ng
�l�0.Ma y�G-L 21.REMARKS 3 f1
D
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / 22.Certific
6.Is(are)the well(s)oPermanent or 13Temporary S' co crti wd Well Contractor Date
By signing 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 ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ixample-3@200'and 22{@100') construction to the following:
10.Static water level below top of casing: L- 1 (ft.) Division of Water Resources,Information Processing Unit,
(f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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
(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 of
13b.Disinfection type: HTH Amount: LI?O 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 j (7 Revised 2-22-2016