GW1-2021-00531_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W01 Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 in. PVC
Company Name
^`1, -� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: oZ I - d W - W 1 V rl Q- 02.Ja 10 3 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSILE 'THICKNESS MATERIAL
Agricultural ®i Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
_ IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
_;Irrl atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft PORT.CEMENT POUR
:_Monitoring EIRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage
Experimental Technology ®j Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock type,grain sim,etc.)
ft. FZ ft. a;
4.Date Well(s)Completed:/�'��• G' well ID# 2 ft. ft.
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) tt• ft ry.y n ..v
50 1>0 r'mss M ifl21 d Me(-P_"S i 11 e.. a 7,5o I ft.
Physical Address,City,and Zip
ft. tt. DEC 2 2 2021
�1 U 1 1 Surd ►�g q 7G�I/� 11 21.REMARKS t�y ��cp��
County Parcel Identification No.(PIN) * DO,`7ECTk
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi6cati
30 ng.�y�` N ?9°yo< �U0 W /� �o-�• Z�
6.Is(are)the well(s)o Permanent or 13Temporary ignat citified Well Contractor Date
By signing this form,I herehv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy gfthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
9.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-I 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: /^' Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdtiferent(example-3@200'aand 2@100') construction to the following:
10.Static water level below top of casing: -Zd (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'.+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l 1.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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: AIR ROTARY 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: .1ZO`4 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016