GW1-2021-00677_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
F �r WellConhactorName FROM TO DESCRIPTION2�J 4 �
4448A
ft. ft. j
r
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. 3 IL 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) {t. ft. in.
lndustrial/Commercial Residential Water Supply(shared) IS.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAYELPACK(if applicablel
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks) FROM TO DES RIPTION(color,hardness,soil/rock e, rain size,etc.)
4.Date Well(s)Completed: _ Well ID# ? Cl`
/5a.Well Location:
`t?
ft.
Facility/Owner Name Facility ID#(if applicable) ft.
ZooZ E?l,e stys �t�•—cam 12 c�t Sth..... , L 343 ft. ft.
] sical Address,City,and Zip ft. ft.
21.REMARKS
pilwo
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) /� ,Q�P 22.Certiticatio .
3L3a s ' �S N -7Iq& 4 p�'0� W
6.Is(are)the well(s)o Permanent or OTemporary Signal of Cenif tractor- ace
B signin is for herebv certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or E)No ith NCAC 0 ..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 y ofthis 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 I GW-1 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: i�I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: .32 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 7-5 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: 57 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 Watcr Resources Revised 2-22-2016