GW1-2021-00577_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CH RI STOPH E R WATCHER 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ,1 ft. jC' fL
4448A "/ U
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 in. PVC
Company Name
�1 ` 16.INNER CASING OR TUBING( eothermal closed-loop)
-A
2.Well Construction Permit#: e HW I D ` - 0c` 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. tt, I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in. .
_J Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. 11
industriaUCommercial DResidential Water Supply(shared) 18.GROUT
_._Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 2D ft PORT.CEMENT POUR
Monitoring DRecoveiy
Injection Well:
Aquifer Recharge E)Groundwater Rcmediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM Geothermal(Heating/Cooling Return) ROM TO DESCRIPTION(color,hardness,soil/rock type,grain sim,etc.)Other(explain under#21 Remarks) ft '7 ft 'S0
4.Date Well(s)Completed: '2 Z Well ID#
ft. ft.
5a.Well Location:
C
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l� I ft. ft.
< ,`�^�
P�st-eal`Ad`dress,City,and Zip ft. ft. Do I '
ct &° 310 4(96'7 21.REMARKS I.r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 100,
(ifwell field,one lat/long is slefficicnt) 22.Certification•
360 Z6.5Ho N -7q°ya•yS-7 W / -z-Zi
6.Is(are)the well(s)oPermanent or 13Temporary Signatu a ell 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: ®Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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: 00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 91 (ft.) Division of Water Resources,Information Processing Unit,
!(ware,•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,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: 20o"Z completion of well construction to the county health department of the county
where constructed.
i
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016