GW1-2022-02872_Well Construction - GW1_20220228

to Form
WILL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We11.Contractorirformation:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM 'I'O DESCRIPTION
4448A
NC Well Contractor Certification Number
15.OUTER CASING(for multi cased wells OR\Li-NE`R�if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 rL 1 fL 6 in. PVC
Company Name 4,
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 '1'O DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural ®I Municipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) ®I Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ElResidential Water Supply(shared) IS.GROUT
_'Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 rt• PORT.CEMENT POUR
Monitoring 13 Recovery
Injection Well:
ft. ft.
Aquifer Recharge ElGroundwater Remcdiation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage
I Experimental Technology 1I Subsidence Control
i Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DF.SC TION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nJ Other(explain under#21 Remarks) O
4.Date Well(s)Completed: 1 'Z` Well ID# 22 ft, no ft. oI
5a.Well Location: V.
I rt. rt.
t w
Facility/Owner apme ^1 Facility ID#(if applicable) ft. ft. FEB
I 1 2d \\Y_ HW�,J\ V / 'v ' R. ft.
Physical Address,City,and Zip
ft. ft.
to P
C`,^^, 1\ t o "l 15 G ate 21.REMARKS
County �Y Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is su?cient) �f Q' 22.Certifi on* �s�
15S`qo-> I I N W 6 l7 . 96 / / W - •22
6.Is(are)the well(s)oPermanent or OTemporary Sign c of ed Well Contractor Date
By signing this form,I hereby certify that the well(v) was(were)constructed in accordance
7.is this a repair to an existing well: Elves or ElNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/(this is a repair,fill out known well construction information and explain the nature ofthe copy o(this record has been provided to the well owner.
repair under#21 remarks section or on the back of!Iris 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: 19()-A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!f different('example-3 n 200'and 2@1001- construction to the following:
10.Static water level below top of casing: ! (ft.) Division of Water Resources,information Processing Unit,
((water level is above casing,use'.+" 1617 Mail Service Clenter,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) 12-& 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: 0-oz. 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