GW1-2021-07561_Well Construction - GW1_20210903

. WELL CONSTRUCTION RECORD GW-11 Fo Err 1111 Form
r Internal Use Only: �
I.Well Contractor information:
CHRISTOPHER WATCHER
Well Contractor Namo 14sWATER ZOrIES
FROM
4448A t rO D DESCRI...o
V J_.R. � � fi:' 1
NC Well Contractor Certification Number ft R.
CUMMINGS DEVELOPMENTS, INC ROOU TERCAO
ING(foc;multieased wellsY OR'LINER"ffiilwlcaiile .1
DIAMETER THICKNESS MATERIAL
Company Name - +1 ft'. f• e In. !.5/8 G.STEEL
2.Well Construction Permit# , Oo16.IMNNER CASING ORTOBING;`eoYhei m- 188 hclos`ed=loo _
List all applicable well construction FROM/i.e,UIC,Cotmty.Stale,4arianre,err.) R• TO R• DIAMETER i THICKNESS MATERIALf
in.
3.Well Use(check well use):
Water Supply Well: I7..SGREEN
Agricultural FROM to
E]Municipal/Public DIAMETER I SL yrSI7E THICKNESS MATF,RIAL
Geothermal(Heming%Coolin Su 1 f' R• 1°•
g Supply) I'Resideniial Water Supply(single)
IndustriaUCommercial R• ft. in, I
Residential Water Supply(shar`e'i);
Im ation
FR Gi .Nnn_�>Sra!er yer I Wew; T". r — __A —_sn " _ —
MM Y- � - - `�•�� - •"Sa7PLAC� ENT(METHOD&AMOUNT
O R• ft.
Monitoring Recovery v� U�
Injection Well: ft. R.
Aquifer Recharge DGroundwater Remediation ft. R.
Aquifer Storage and Recover 1
Y DSalinity Barrier 19-'SAND/GRAYEL)PACK- fa -licablE
FROM TU MATERIAL(
Aquifer Test 13Stolmwater Drainage ft. ft. EMPLACEMENT METHOD
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer y
Geothermal 20:;DRILLING LOGi a"ttaehiadditionalil eiets,lf,eeeesss": - • v.(Heating/Coolin Retum) Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardnern solUroek e," n sit,etc.►
R. �f ft.
1
4.Date Well(s)Completed: —j —Z Well 1D# ft. G
A2 R
Sa.Well Location: R. R
R• ft. C
Facthty/Owner Name Facility ID#(if applicable) 43 ft. f
-4ft. �
Physical Address,City,and Zip II\9
R. R• � � t10'� tptl
Cl 801 t) -b 59 21 REMARKS
County
Parcel Identification No.(PIN)
I i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if wolf field,one lat/long is sufficient)
3/p u p Sb 3 N 22.Certifica
ZG�—f� ,' i W 7
6.Is(are)the well(s)OPerinanent or oTemporary ure of Certified Well Contractor
By signing this form,I herebv certify that the wrll(sJ was(were)constructed in accm'dance
7. hx is�a repair to au existing well: Yes or �No with ISA NCAC 02C.0100 or ISA NCAC O1C.0200,IYeII Conshxrclion Standards and/ha!a
fC1h/s is e/repair,fill otn known construction hr nnation and rrpla/n the aalrire ofthe coDY ojthN record has been provided to the well owner.
repair under#2I remarks section or on the back oflfrfs fornn.
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:
9.Total well depth below land surface: A?1 SUBMITTAL INSTRUCTIONS
For Rim/lip/r wells list all depths ifdifferent(example-3 eci 200'aad 2Qf00,) (ft') 24a. For 1 Wells
�. Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
ifWarer•level Is above casing,Rise + (ft.) Division of Water Resources,jinfor•mation Processing Unit,
11.Borehole diameter; 6 1617 Mail Service Center;Raleigh,NC 27699-1617
(1n.) 24b.For InieCti2 Wells: In addition tb sending the form to the address in 24a
12.Well construction method: ROTARY above,also submit one copy of this form within 30 days of completion of well
0-e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test: � ; � `
24c.For Water Suonly&Iniecfi��Wells: In addition to sending the form to
13b.Disinfection type: HTH the addresses) above, also submit one(copy]of this form within 30 days of
Amount: completion of well construction to the county',health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016