GW1-2021-02124_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 7
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
4448A fr. fr. 2
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for mulfl-eased wells OR LINER if a Gcable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 2, ft' 6 5/8 Im• .188 STEEL
Company Name
p, 16.INNER CASING OR TUBING(geothermal closed-loop
(� 1 2.Well Construction Permit#: •48 W JR N FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) ft. fL in.
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREEN
FROM 'I'O DIAMETER SLOT SIZE 'THICKNESS MATERIAI.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fr in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT _
Irri ation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 2� ft. d� G
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. fr.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
O ft. ft. a i
4.Date Well(s)Completed:�- 2 Z t Well ID# ft. 496 ft.
5a.Well Location: ft. ft.
ft. ft.
rA04," L-e Vv't S
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3-;14 S Cobb F41r .M «. ft. 10 J N
T�. �Nt,a.htar.., a��oa
Physical Address,City,and Zip
ft•_J ft' cocagsing Unit
C1 r& e 21.REMARKS
_ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is s f
fficient) p G 22.Certification:
36° io • yas N � � 0 •SVL ' W -Z
6.Is(are)the well(s) Permanent or 13Temporary store o led Well Contactor Date
y signing"his form,I hereby certify that the wril(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfrhis it a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thus 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: f� SUBMITTAL INSTRUCTIONS
f
9.Total well depth below land surface: APO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3 (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) 2 K Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
`9 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: APO Z 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