GW1-2021-07394_Well Construction - GW1_20210921

P,,rint Fom
.11111111ICONSTRUCTION RECORD LGW-11 For Internal Use Only:
1.Well Contractor Information: ,
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4448A
ft. ft. z 4
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cummings Developments, Inc FROM TO I DIAMETER T THICKNESS I MAT AL
ft. ` ft. in. /A� �
Company Name CJ'A F-` 16.INNER CASING OR TUBING 'eothermal closed-loo -
__
2.Well Construction Permit#: �0 O 101 ,W et N 2 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. ft. rn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM to DIAMETER SLOTSIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. fr. in.
:]Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
_j hTlgatlOn FROM TO M TERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. - ft. O A
:.)Monitoring DRecovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
"-
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test nj Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
w'% FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sim,etc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) ft. rit- `
4.Date Well(s)Completed: .� Well ID# ft. / ft.
5a.Well Location:'Sam
ft. tt. `
e, Z' L�
Facility/Owner Name Facility ID#(if applicable) ft. ft. Illy
l Mot ram ` \\ 2 A (fi,,'� a1 tt. re cotes ' �J
Physical Address,City,and Zip q C, ft. ft. OlC('J RCjB
_A`QW�AC C 1 ^7 1 p 7 y 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) ( 22.Certificatio
350 5 _ 65C) N �9 �l� -2tS W
6.Is(are)the well(s)IRPermanent or 131remporary Signature of C ell Contractor Date
signing this farm,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: nVes or MNo with 15A NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 I 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 ifili ferent(example-3@200'and 2@/00) 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
11.Borehole diameter: 6 (in.) 24b.For Injection 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
�f r
13a.Yield(gpm) ^4 5' Method of test: L 24c.For Water Supply&Injection 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: �. 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