GW1-2021-07424_Well Construction - GW1_20210921

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WELL CONTSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W411 Contractor Information:
Christopher Watcher
14.WATER ZONES
ON
Wc1l Contractor Name PROM f0 UESCRPTI
- V)
4448A 2-
NC.Well Contractor Certification Number 10 G multi-cased Is)FOg L OUTER CASING(for Lee, LINER 1191)pka OM THICKN
ESS
,ek
Cummings Developments, Inc I TO DIAMETER I MATERIAL
N . to t. 6 in.
Company an,.� ol) ft f I . I PVC
�e-t' 16 INNER CA ING ORTUBING(keothermat closed-loop)
2.Well Construction Permit W FROM TO DIAMETER THICKNESS _ MATERIAL
List all apldicci;h, inits(i,e.UIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(zllcok viell use): ft. ft. in.
17.SCREEN
FROM TO -_ DIAMETER_I st,o'rsizt, THICKNESS MATERIAL
A. ricuitt:rat [)Municipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
.idential Water Supply(shared) 18.GROUT
FROM TO A EMPLACEMENT METHOD&AMOUNT
UNon-Water v Well: ft. ft. (: e6!
aMcmit..., InRecovery ft. ft.
Injection%",-1: ft, ft.
n,Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Q1 A __ - - gu and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
q"A,,u�te'��qit�il,�� LIStonriwater Drainage ft. ft.
0�y OSubsidence Control
'""menw, I echno;
--suL!Loop) OTracer 20.DRILLING LOG(attac additional sheets if necessary)
ION PROM TO DESCRIPT kolur,bardom,soittrock type,grain sim,etc.)
cr" Heating/Cooling Return) 0;Other(explain under#21 Remarks)LGe'2th
ft. ft. Tc.-1,
4.Date Wellis)Completed: 10 �t Well ID# ft, ft-
Sa.Well Location: ft. ft-
h� a..cY.-
ft.
Facility/Owner N,,i ncCC Facility 113#of applicable) ft.
0.1 ."a an C %rM_A5 ft. ft.
Physical Addre.,,,City,and Zip ft. ft,
21.REMARKS
County Parcel Idenfification No.(PIN)
5b.Latitude and iongitude in degrees/n-tinutes/seconds or decimal degrees:
(if well field,on:;at/long is sufficient) 22.Certificatio
A0 m $i ' N 10 -W
6.ls(arc)the ivc!!(S).0Permzrcnt or E)Temporary K11"Irc crti ed Well Contractor Date
signing this form,I hereby certify that the iveil(v)was(were)constructed in accordance
7.Is this a repair to an existing well: C)Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC I 02C.0200 Well Construction Standards and that a
I'this is et repairfill wa known ivell construction information and explain the nature orthe copy of this record has been provided to the well owner.
repair under#2/renrarks section or on the back ofthisforni.
23.Site diagram or additional well details:
8.For GeoprobeiDPT or Ciosed-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 C-W.-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessa .
I y necessary.
drilled:---- SUBMITTAL INSTRUCTIONS
9.Total welt t 3-below land surface: —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formid"ilie x rs_m ail depths i(dil/erent texample-3@200'atid2@100') construction to the following:
hi
10.Static wat;-r level below top of casing:
ifivaterk-vel is""ove casing,use'+ (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter:.6 (in.) 24b.For Injection Wells- In additiol I to sending the form to the address in 24a
Rt:ltary above,also submit one copy of this form within 30 days of completion of well
12.Well coris.. ineiliod:
construction to the following:
(i.e'au&Cl, Push,Cwj
Division of Water Resources,Underground Injection Control Program,
FOR W TEt;_S_:PFLY WELLS ONLY: 1636 Mail Service Center,! Raleigh,NC 27699-1636
13a.Yield(gp 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.ffisinfectics_ roe: HTH
Amount: 0z completion of well construction to the county health department of the county
where constructed.
I
Form C1\1-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016