GW1-2021-00552_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 1 I I If
ft. ft. 2 9^?C 4{
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case&Lvells OR LINER it a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 75 ft. 6 in. PVC
Company Name
� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 001 " ^000.^�157 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) tt. ft. in.
_j Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG`(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc.)
_'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 2 ft
(-
4.Date Well(s)Completed: Z t Z� Well ID# 7z2_ S Co rt. ")6
5a.Well Location:
OLAD ZSc ft. ft.
Facilit er Name Facility ID#(if applicable) ft. ft.
eta
W 45 11 cle-e> ,L-:D 1✓ ft. Ift. ..
r,
Physical Address,City,and Zip ft. I ft.
21.RE
MARKS
County Parcel Identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long i sufficient)
t t 22.Certification )
3G001t Jot N �q0 011529 w /"'� I►-Z�t.-z�
6.Is(are)the well(s)oPermanent or ractor Temporary ature o rtified Well Cont Date
y signing this fmm,I herehv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or InNo with 15A NCAC 02C.0100 or 15A NCA602C.0200 Well Construction Standards and that a
If 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 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 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: O O (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'andd22@100) construction to the following:
10.Static water level below top of casing: I (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,ere.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 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: �oz 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