GW1-2021-00475_Well Construction - GW1_20211222

Pent Formj=y71
*ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM '1'O DESCRIPTION
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased(wells OR LINER if a lieable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 in. I PVC
Company Name
���� ��� � I 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W 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):.I ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) tt. ft. in
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ ItTI atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• PORT.CEMENT POUR
Monitoring ©Recovery
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation 19.SAND/GRAVEL PACK if applic2ible)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stomiwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling`Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION,color,hardness,soil/rock e, rain size,etc.)
y.1 it. S n 1
4.Date Well(s)Completed: 1�j J Well ID# y ft. 2( ft. o
5a.Well Location ft. ft.
rt l E�X� 1✓�- ft. ft. ; ;= "'ii 3
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
P1k1i4s'1� ��,f� .._ ft. ft. DEC 2 2 2021
Physical Address,City,and Zip ft. ft.
21.REMARKS �161dN�
a rLe $�5n3`i a5�y 1,tVrWAle. tc,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onnee/lat/long is
sufficient) Q p 22.Certification:
N r /� �I W
6.Is(are)the well(s)o Permanent or OTemporary S' ature of ifi e I Contractor Date
sng ung this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or EJNo with!SA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair.fill oul known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 pagelto provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �y Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �``� -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and12 eJ100') construction to the following:
10.Static water level below top of casing: `� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 WE.LLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(
13a.Yield(gpm) 13 ( Method of test: AIR ROTARY 24c.For Water Supply&Infection 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: VD 2 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
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