GW1-2021-07399_Well Construction - GW1_20210921

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-T W21 LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
es'
1.Well Contractor information:
CHRISTOPHER WATCHER �j � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
4448A
0 r✓y ft. ft.
NC Well Contractor Certification Number N� `o�(�t PG��O� I5.OUTER CASING(tor multi cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC\V,,0 s 3 gA?'J� FROM TO DIAMETER THICKNESS MATERIAL
.1 ft. ft. 6 5/8 , in. 188 G.STEEL
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM 1110 DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. fL in.
Geothermal(Heating/Cooling Supply) Er;-SJOADesidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft PORT.CEMENT POUR
:)Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Rcmediation ft.
19.SAND/GRAVEL
GRAVEL PACK(if a licable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test []Stonmwater Drainage
Experimental Technology Subsidence Control
I Geothermal(Closed Loop) JDTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 1_ Other(explain under#21 Remarks) FROM ft To ft DESCRIPTION(color,hardness,soil/rock e, rain size,etc.l
4.Date Well(s)Completed:V✓� Z` Well ID# S C
ft. ft.
Sa.Well Location:
Facility/Owner Name Facility ID#(if applicable)
p 5!1 H-,v �1
Physical Address,City,and Zip
ft. ft.
1 r G ?C 21.REMARKS
1'County y` Parcel identificatition No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) f 22.CertiSca
5�� 2, ?,- 2t-
6.Is(are)the well(s)oPermanent or Temporary Signatur ell Conrractor ate
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: 13Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tfthis 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-I 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 ifdifferent(eranrple-3@200'and 2@100') 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
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: 32A Z 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