GW1-2021-00675_Well Construction - GW1_20211222

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Print Form'
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO LDESCRIPTION
4448A rt. rt. ?'R '41049
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INCH FROM TO DIAMETER THICKNESS MATERIAL
+1 I'L 1 kJ4 It. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIA_11L
Agricultural J unicipal/Public tt. ft. in.:
Geothermal(Heating/cooling Supply) ;Residential Water Supply(single) ft. ft. in.
_i Industrial/Commercial Residential Water Supply(shared) 18.GROUT
i Irri ati on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring aRecovery ft. rt.
Injection Well:
(t. ft.
Aquifer Recharge J Groundwater Rcmediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
I Experimental Technology Oi Subsidence Control
Geothermal(Closed Loop) O Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiVrock e,grain siu,ere.)
- 3Y ft.
4.Date Well(s)Completed:11D- '7r Well ID# /Wd•
5a.Well Location:
Facility/Owner Name .,Facility ID#(if applicable) ft. ft.
,N 1 6- G LLK fJpri M S C kWJA VA rt. rt.
Physical Address,City,and Zip kJ ft. tt. Map - Y
(\I-_,r-- 21.REMARKS r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 22.Certification:
3so 10. 'M f N `710 0, --50
6.Is(are)the well(s)0Permanent or 13Temporary ,gnal- crtificd Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were,)constructed in accordance
7.Is this a repair to an existing well: rJYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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: (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'mldQ2@100') construction to the following:
10.Static water level below top of casing: 1 (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,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) 'Z 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: /IL 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