GW1-2021-02125_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.*0 Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM I'o DESCRIPTION
ft. ft.
4448A .7 S'd-5
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 0eable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 19 it. 6 5/8 in. .188 STEEL
Company Name
�
G✓L 21 16.INNER CASING OR TUBING(geothermal closed-loop
(J
2.Well Construction Permit#: 4 • N FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etr.) 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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [9residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO TER1.4L EMPLACEMENT ME'I HOD&AMOUNT
Non-Water Supply Well:
Monitoring 13 Recovery
Injection Well:
Aquifer Recharge []Groundwater Remediation ft• ft.
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock is a rain size,etc.)
Geothermal(Hearin Coolin RReturn))✓Z`Other(ex lain under#21 Remarks) fr I"D ft
�2 a'
4.Date Well(s)Completed: Well ID# 1 it• /0 ft.
5a.Well Location: ft. it.
en
ft. ft.
boor
Facility/Owner Name Facility ID#(if applicable) ft. ft.
(P4 39 meals• 'g A Snoj. CLI kAp 27 34 9 illy
Physical Address,City,and Zip ft. ft 3tlOn Proces
S,r!l0 9 05? 8 44 21.REMARKS L1Lrrr`trGZ''u'C_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loongg is sufficient) Q�i 1 22.Cer tificatio L'/
35°s� •Zz9 , N ` Z4• 1C7 + W /1�Zq .'L1
6.Is(are)the well(s)mPermanent or Temporary tore of Certified Well Contractor Date 1
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
grthis 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 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@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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)_ 7? - Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: J zJz 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