GW1-2021-02015_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRI ION
' (�
4448A �
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
.1 ft. r� ft. 6 in. PVC
Company Name ./ 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: )7 I �OLi�% 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 E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
-]Irrigation FROM TO M Ent L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e7 ft. ft. r e o..
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [OStormwater Drainage ft ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Hearin Coolin Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION tcolor,hardness,soil/rock type,itnin sim,etc.)
ft. / ft. a
4.Date Well(s)Completed: r O� /Well ID# ft. g ft. ,1 C�
5a.Well Location:
To1kA D 'RIt i Ideys
Facility/Owner Name Facility ID#(if applicable) ft.
2 21 rarer C1Q.�e_ 'be-, ft. ft.
Physical Address,City,and Zip ft. U N 2 `J(�
2021
21.REM1iARKS
County (� Parcel Identification No.(PIN) Information Processing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certificatio
3(O -3/1 N O�I��•7 W Z
6.Is(are)the well(s)oPermanent or Temporary gnat Certified Well Contractor ace
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: OYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
/fthis 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#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: 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®100'and)2@100) construction to the following:
10.Static water level below top of casing: �V (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) Method of test: 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: �Q L 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