GW1-2021-00554_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
C H RI STOPH ER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIP7'lON
ft- ft. .L
4448A
ft. ft.
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
^^� 16.INNER CASING OR TUBING eo'thermal closed-loop) '
2.Well Construction Permit#: �a I -� 001a3 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 SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o tt' 20 ft PORT.CEMENT POUR
Monitoring 13Recovery
Injection Well:
_,Aquifer Recharge Groundwater Remediation ft.
19.SAND/GRAVEL
GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [i Stormwater Drainage
Experimental Technology 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 ft• DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
© ft Z O1,
4.Date Well(s)Completed: Q Z Well 1D# 2-1 ft. r-42- o`l
5a.Well Location:
ar0.,�.�� BECft. tt. .
Facili ner Name Facility ID#(if applicable) ft. ft.
o A
�O I{.5 1 A- C,►fAd ft. ft. INFOWAMM M-J(GSgii f(-(j,!
Physical Address,City,and Zip
ft. ft.
0r c>LV�[a� ggg I clUl all 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 10,
(if well field,one Iat/long is
sufficient) 22.Certificad .
• � �� ` Jd'1 N lil�_P�7� W /a Iq-z-1
6.Is(are)the well(s)oj Permanent or OTemporary gnature a led Well Contractor Date
By signing This form,1 herehv certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: OYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 9 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 ifeli ferent(example-3@ 00'and 1Q100) construction to the following:
10.Static water level below top of casing: L' (ft.) Division of Water Resources,information Processing Unit,
ff water level is above casing,use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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
13b.Disinfection type: HTH Amount: 34762 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