GW1-2021-07393_Well Construction - GW1_20210921

�, j Frint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
' 1.Well Contractor Information:
CHRISTOPHER WATCHER 14:wArE>zzoNEs
10 Well Contractor Name FROM TO I DESCRIPTION
4448A
ft. ft. ')
NC Well Contractor Certification Number 0. (5
15JD1UTER,CASING'tfor;multi cased wells LINER if a"' iicable
CUMMINGS DEVELOPMENTS , INC FROM I TO I DIAMETER THICKNESS MATERIAL
Company Name
+1 ft.
19) ft. 6 6/8 1n• 1 .188 G.STEEL
n�, 16"INNER,V"ASING ORTUBING;'e'ot tri7 Uclosed-loo 'L
2.Well Construction Permit#: A4u�y i"/� ry\(,,.�v Z t DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17:,SCREEN " "...
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Olesidential Water Supply(single) ft. ft. In.
.!Industrial/Commercial OResidentiai Water Supply(shared) 18.GROUT
_. Itri gallon FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. PORT.CEMENT POUR
Monitoring _!Recovery ft. rt.
Injection Well:
ft.Aquifer Recharge _Groundwater Romediation it.
19!SAND/GRAVEL PACK(if apolicablel._
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control rt. ft.
Geothermal(Closed Loop) Tracer iO:;DRILLING-LOG attaeh_additionahsheets Mnecessar).
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock a rain size,etc.)
ft. ft. ) s
4.Date Well(s)Completed: - ""Z Well ID# ft. Z� ft. 4
5a.Well Location:
r-2 � ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1T13 1-1
�3tro 5 a k IU t` (M HMA4
Physical Address,City,and Zip tY, ft. C{,�t�(1 CllOB
21,REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is suTcicnt) 22.Certificatio
3(e0 Oil &� I N �9' z .7x � ' W to
6.Is(are)the well(s)OPermanent or OTemporary S19afErc of C red Well Contractor Date
8 'ping this form,l hereliv certify drat the well(s)was(were)constructed in accordance
?.Is this a repair to an existing well: [3Yes or E)No 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 tare well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional welt.details:
&.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(example-3 tt 200'and 2Q1001 construction to the following:
10.Static water level below top of easing: 30 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method ROTARY 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 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: 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