GW1-2021-00533_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 'I'O DESCRIP'ON
ft. ft. Q 2
4448A v w
ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER if a licable
CUMMINGS DEVELOPMENTS , INC FROM I TO DIAMETER I THICKNESS I MATERIAL
+1 ft. l ft' 6 1 in. PVC
Company Name �.
^ yt �) 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: er j — 0 rj WN i-}iL• ��L b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. I ft. in.
i Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in,
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 tt PORT.CEMENT POUR
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Rcmediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Storniwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO
To fL DESCRIPTION(color,hardness,soil/rocke,grain size,ere.(
4.Date Well(s)Completed: (I Z"2 I Well ID# ft. IL
Sa.Well Location:
ft. ft.
-
W\��\
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
WMI K ,,. ►�. '��. C��� ,t�„ ft. DEC 2 2
20
Physical Address,City,and Zip ft. ft,
21.REMARKS
e9 F`t
County Pat-cc]Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lan'long is su / 22.Certificati
fficient)
350 0. 4V I N 790 (4qt oa$ w
6.Is(are)the well(s)oPermanent or OTemporary at Cc red Well Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lutown 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 or on the back of this 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 l 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: ��� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
/fwater level is above casing,use,.+,. 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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) 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
lJ
13b.Disinfection type: HTH Amount: ,201L completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016