GW1-2021-07423_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER M WATER'ZONEs
Well Contractor Name FROM '1'O DESCRIPTION I
4448A O'�, 0 IS' ft. 101 f. Z v I I
NC Well Contractor Certification Number
e 21 2 �Il\'4 ft. ft. I I
s-0A 15.OUTER CASING'for muni-caied"`ells OR LINER+'if+a"l(cable
CUMMINGS DEVELOPMENTS, INC � ��OGQ i(aC1 FROM TO DIAMETER I THICKNESS MATERIAL
Company Name �J(1-• Q +t ft• fL 6 5/8 I in. 1188 G.STEEL
i MANNER CASING OR TUBING; eo'4herm l lielosed-loo
2.Well Construction Permit#: G>(9 k A 1` S FROM I TO DIAMETER I I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) R• ft. I in. I
3.Well Use(check well use): ft. ft. (in. I
17.SCREEN I ;:;
Water Supply Well:
FROM TO DIAMETER i SLO'14S1ZF I THICKNESS I MATERIAL
Agricultural 13MunicipaUPublic ft. ft. in• ! j
Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft- ft, in. I I
Industrial/Commercial DResidential Water Supply(shared) 18;GROUT: ,r_1-
Irrigation FROM TO TERIAV EMPLAC c ENT METHOD&AMOUNT
Non-Water Supply Well: ft. 74 ft.
Monitoring DRecovery ft. ft. I
Injection Well: ft, ft I
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVELPACK.if a lkabl
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL I I EMPLACEMENT METHOD
Aquifer Test DStomtwater Drainage ft' f• I I
Experimental Technology DSubsidence Control fL ft. I
Geothermal(Closed Loop) OTraeer 20."DRILLING LOG attaeh-addlttokial s`lieets if beeessa }...:..-'
Geothermal Heating/Coolin Return) _ Other(explain tinder#21 Remarks) FROM To DESCRIPTION(color,hardness oil/rock q rain size etc.i
ft �S ft I } j
G 1 i
4.Date Well(s)bbmpleted: � _ Well ID# q2 ft. 120
ft. '
I
Sa.Well Location:-
FacihtytOwncrName Facility ID#(ifapplicable��ay3 ft. ft.
3 1-At^t mola w r_�\1 vc."1 cl [4IW
Physical Address,,City,and Zip I H• fL
Dan" _ 21.REMARKS
County VV
Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j
(ifwcll field,one Nulling is sufficient) �jQ► y �` 1 22.Certifica'
flab f. 917^ N l I pt j t ? � W ! I 7_ J`
6.Is(are)the welt(s)opermanent or 13Temporary ure ofCcrtifrcd Well Contractor Date
By signing this form,I herebv certify that thr wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EJNo witli 15A NCAC 02C.0100 or 15A NCAC 02C.020011VeIf Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy gfthis record has been provided to the well owner.
repair under#21 remarks section or au the back of this form.
23.Site diagram or additional well detlails:
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: /;?0 24a. For All Wells: Submit this forxli within 30 days of completion of well
For multiple welts list all depths if different(example-3 u 200'and 2Q100'} j
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,llnformation Processing Unit,
Ifwater lavel is ahorc casing use 1617 Mail Service Center,;Raleigh,NC27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition t�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: 1 jl1
(i.e.auger,rotary,cable,direct push,ate.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccnter;Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: 24c.For Water SuDDIv&Infection Wi Ils: In addition to sending the farm to
136.Disinfection type:
HTH / the address(es) above, also submit'onel copy of this form within 30 days of
Amount:/ Vz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Enviromncntal Quality-Division of Water Resources V Revised 2-22-2416