GW1-2021-00463_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW 1) Prrnt Forn '
For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER
14;WATER ZONES ;
Well Contractor Name FROM =TODESCRIPITION
4448A ft•NC Well Contractor Certification Numberft•
15.OUTER CASING(for multi-caie&wells OR LINER'if a licable),CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. �4 ft. 1 65/8 in. 188 G.STEEL
"� 16:INNER CASING UWFUBING:'eothermal closed=moo'2.Well Construction Permit#: L-'4 9``{5 63 G LN 2 I FROM TO DIAMETER THICKNESS MATERIAL
List all applieahle well eoustrrrrtion permits(i.e.UIC,County,State,I urimue,err.) ft. (r. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN -
Agricultural FROM 't'O DIAMETER SLOTSIZE THICKNESS MATERIAL
Municipal/Public fr. ft. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single)
ft. fr. in.
Industrial/Commercial 13Residential Water Supply(shared)
hri ation 18.GROUT. -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:Monitoring o it 20 rt
PORT.CEMENT POUR
Recovery ft• ft.
Injection Well:
Aquifer Recharge [jGroundwater Rcmediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if licable
FROM TO MATERIAL EMPLACEMENTDtETHU D
_ Aquifer Test �StonnwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING LOG attach-additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sowrock e, rain size,erc.l
vvI
4.Date Well ft. �' ft.
s)Completed: � "7' 2 Well ED# q'� rr. 20 ft. RoA
5a.Well Location:
ft. ft.
Facility/ amc p
Facility lD#(ifapplicablc) ft• ft. r
rq
�_1.11 cell tio. A ✓�i ti4 �l e111 rt. ft. VV 202
Physical Address,City,and Zip ---a ft. ft.
4 C- -e— 019 00 Z 19 Q 1 3 21 REMARKS
County Parcel Identification No.(PIN) 4l �Ot? +ft(4f-SS ►1 I.R;
r:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is suffi fient) 1
�'O , —1 3 1 N O I +' q zq 22.Certi6catio
. W
_
zl
6.Is(are)the well(s)oPel manent or oTemporary na of C ell Contractor Date
By signing this form,I herebv certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ONo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy 4fthis record has been provided to ire hell owner.
repair under#21 remarks section or on the back oJ7his 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:
�
9.Total well depth below land surface: 2 SUBMITTAL INSTRUCTIONS
(ft.)
For multiple wells list all depths ifdi(ferent(example-3@200'and 2@1001 24a. For All Wells: Submit this form within 30 days of completion of well
n construction to the following:
10.Static water level below top of casing: � (ft)
Ifivater•level is above casing,itce•-+' Division of Water Resources,Information Processing Unit,
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
12.Well construction method: ROTARY above, also submit one copy of this]form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
,,►►11 ••-q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) llo/ Method of test: AIR ROTARY 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: HTH
the address(es) above, also submit lone copy of this form within 30 days of
Amount: 2-0 Z completion of well construction to the county health department of the county
where constnicted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016