GW1-2021-07395_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C H RI STO PH E R WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4448A .1
ft. Aga ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased;wells OR LINER if a Iicable
CUMMINGS DEVELOPMENTS, INC FROM TO^ DIAMETER THICKNESS MATERIAL
*1 II• ` It. 6 5/8 in' .188 G.STEEL
Company Name
t� 76.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: 3a`{ LJ E L t�Z` FROM TO DIAMETER THICKNESS MATERIAL
Litt all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. fr. in.
Industrial/Commercial 13Residential Water Supply(shared) IS.GROUT
_ hTi ation FROM TO MATERIAL EMPLAC ENT METHOD&AMOUNT
Non-Water Supply Well: 0
Monitoring 13 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicaible
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP"ION c lor,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 1 ` 1 Well ID#
5a.Well Location:
Carol Z"kan.%
Facility/Owner Name Facility 1D#(if applicable)
4a5,,7 Nc 5 t4 H W v1 Gv&i-,&, ,was 3 " \
Physical Address,City,and Zip ft.
W^60 fro
21.REMARKS 5
/ e// Qt �O
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A
O(Cr Vv
(if well field,one lat/longis sufficient) e 22.Certification:
(� Q
-1
6.Is(are)the well(s)0 Permanent or Temporary Signa ofCcrtifrc c ntractor Date
y si t is jm•m,l herebv certify-that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No a /SA NCAC 02C.0100 or ISA 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#2I 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: 20 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 ijdii ferent(example-3@200'mid 22�@100') construction to the following:
10.Static water level below top of casing: 39 (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 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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/13a.Yield(gpm) V 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: Z Do-z completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016