GW1-2021-00473_Well Construction - GW1_20211222

For Use Only: _7,
WELLCONSTRUCTION RE ,-0RD(GW_J) FL
'i I.Well contractor Information:
CHRISTOPHER WATCHER
well Contactor Name 142 WATER ZONES V
4448A FROM ft. ft. DFSCRI 'JON
NC Wcll Contactor Certification Number ft.
4&OAS0dr,muI&casod,WeIls)OR
CUMMINGS DEVELOPMENTS , INC MUM UTERCTOING Hcable
Kilts
Company Name +1 DIAMETER MATERIAL
G.STEEL
2.Well Construction Permit#: 3S to U,')1E Q_2- 16.IN ER CASIN
................................
eothermal-
Es
List all applicable well co"'Th7tra.onpe/70119,1'1'�:1, FROM TO DIAMETER IHICKNESS MATERIAL
3.Well Use(check well use): ft.
; ft. ft. in.
Supply 31 11 1-SCREEN - "J­ .� . ; 1�' " , 11
Agricultural FROM 'to DIAMETER SLOT S
Geothermal(HCating/Coohng Supply) DMunicipal/Public ft. In. SIZE THICKNESS MATERIAL
gesidential Water Supply(single) ftIndusWal/COmmercial esidential Water Supply(shared)rri lion I&GROIJT­;­­
FROM To
1-water Supply Well: a 20 MATERIAL EMPLAC METHOD&
Monitoring Recovery PORT.CEMENT POUR
Injection ft. ft.
'Aquifer Recharge Groundwater Rcmcdiation
Water N
Non-Water
I'J A
Aquifer Storage and Recovery 13Salinity Barrier B-SAND/GRAVELPAICK.It'i liceble
Aquifer Test FROM TO 77—77777- 1
MATERIAL M -
PLACEMENTr,l OD
Experimental
[3StOnlIWater Drainage ft. ft.
xPerimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop)
OTracer 73 7
�,NvDRILL ING110G,11-ftch addillb ai�ehe 1111 f:hecess 6,
FROM TO :214
Geothermal(Heating(Cooling Return) n Other(explain under#21 Remarks) 0 DESCRIPTION(1color,hardness,so ck e. In size,etc!)
4.Date Well Completed: ft.
AA1F=M well ID# 'S-0 ft.
52.Well Location: I/-10*1,( ft.
Facility/Owner Name Facility ID#(if2pplicable) ft. ft.
9 ft.
Physical Address,City,and Zip ft. ft.
N o
Ur
- A County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lattlong is suftic1cm)
N '7-q * 17. 7SZ) —W 22.Certificatio
6.Is(are)the wcu(s)OPermument or oTemporary Sign ire ofCcrtif ontractor
Vale
7.Is this a repair to an existing well: nVes or JMNo signio 114%form,I herebv ceji6-that thi,well(s)was(were)
cOPYOfIlli,yrt,coi-dlta.tbeeiipi-ovidedioiliI wellollner.ell Construction Standards and that a
If this Lc a repair,fill 0,11 known well CO)U11,11clian NCAC 02C.0100 or 15A NCACi02C.0200 W cOnStructed in accordance
-Olt the back ofthisforal. e
repair under#21 remarks section a# iftformalion and exple;1I Ibc nature qfl
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-I is needed. Indicate TOTAL NUMBER of wells
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: S U
SUBMITTAL INSTRUCTIONS
ror maltiple welt'listall dePlbs 0901vnt(example-3(i_0200'and 2@ 001
(ft-) 24a. ERLAIL3M: Submit this form within 30 days of completion of well
10.Static water level below top of casing: construction to the following:
ifivater level Is above casing,use ,+,, Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection 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 PLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) I
—15— Method of test: AIR ROTARY 24c. For Water Su only&Injection
I IWells: In addition to sending the form to
) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH 0 the Zdrcs
Amount: i
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