GW1-2021-00470_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A V?
ft. ft. wl
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if ap licable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
.�1 ft' Li 2 ft. 65/8 in, .188 G.STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 4510 WEL Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ID ft. 70 ft. rF 1 CtvJ
Monitoring QRecovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®J Stormwater Drainage
i Experimental Technology DSubsidence Control
Geothermal(Closed Loop) niTr'acer 20.DRILLING LOG(attach additional sheets if necessar
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
_J Geothermal(Heating/Cooling Return) _Other(explain tinder#21 Remarks) )J
4.Date Well(s)Completed: t 'Z, Well ID# No
o ft.
5a.Well Location: ft. / ft.
TIA DxvlS _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
36 NEil N N C, 1 121 H W u tQ 7-'W ft. ft.
Physical Address,City,and Zip c7 c� r ft. ft.
N(Jsm(><rnC� e 1 �.O (n 0J 21.REMARKS r 4G UN..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suiricient) I 22.Certification
540OgI9yl Ntc�-g�t W
6.Is(are)the well(s)oPermanent or OTemporary �Signa of Certi Contractor Date
Ig this form,1 herew certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• DYes or ONo NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section at-on the back of this farm.
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 I GW-1 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: ! o lJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-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,
f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: tt 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:Ail, 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: ! �O? 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