GW1-2021-00557_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For rnte r Print Form
i
rn I Use Only:
I.Well Contractor Information:
CHRISTOPHER WATCHER f
14.WATER ZONES
1 Well Connector Name FROM TO DESCRlrFlON
4448A ' ft. �,'' ft.
NC Well Contractor Certification Number ft• ft.
15.OUTER CASING(for multi-eased, Hs;OR;LINER;if a' licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETE R THICKNESS MATERIAL
Company Name � +1 ft. O qL k, a in. PVC
2.Well Construction Permit#: W)�'' OZZ� 16.INNER CASiNG OR TUBING; ea thermal-closed400
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Vaiance,etc.) ft• ft. in.
3.Well Use(check well use): R• ft. in.
fAgricultural
Supply Well: 17.-SCREEN: _
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
MunicipaUPublic ft. ft. in.
hermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.strial/Commercial E)Residential Water Supply(shared) 18.GROUn- anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft.
PORT.CEMENT POUR
Monitoring 'Recovery
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Rcmcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licatile
FROM TU MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stomiwater Drainage ft ft.
Experimental Technology Subsidence Control R. ft.
Geothermal(Closed Loop) Tracer 29.DRILLING LOG attach addithmal,sheets if'necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,solurock e, rain size,etc.(
p n. 'T ft. Sa 1
4.Date Well(s)Completed: f -U-Z1 Well ID# ft. Gl
5a.Well Location: D. ft.
ft.
9�
Facility/Owner Name Facility ID#(if applicable) ft. ft. N
adty ft. -
Physical Address,City,and Zip ft. ft.
Or-Y1eA - 9 9`k 7 a 5-S0 S a 21.REMARKS
County Parcel identification No.(PIN) e
�r`t� P f-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica n
3 LO— all N ?9°IIr7iz' W
6.Is(are)the well(s)opermanent or E3Temporary s• aturc of r ell Contras or Date
By'7.is this a repair to an existing well ng this form,1 herrbv certify that the well(s)was(were)constructed in accordance
YeS or �No with 15A NCAC 02C.0100 or ISA NCACI02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature afthe copy gfthis record has been provided to tilt•well owner.
repair under#21 remarks section or on the back of this farm.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: o
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
if water is above casing,use"+Static water level below top, casing: (ft.) Division of Water Resources,information Processing Unit,
If
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: ROTARY above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �J Method of test: AIR ROTARY 24c.For Water Suoaly&Iniection Wells: In addition to sending the form to
HTH / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: /COO Z 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