GW1-2021-00733_Well Construction - GW1_20210401

WELL CONSTRUCTION HAgQ GW-D For Internal Use Only:
1.Well Contractor Information:
Christopher Cummings 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3170A fr. ft. a q
ft. ft.
NC Well Contractor Certification Number 15.OUTTER CASING for multi-cased wells OR LINER if a livable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+� ft ft. 6'5/8 in• .188 Galt Steel
Company Name
,'\
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#:33 n n ► 1ti;1-L IV C= FROM I TO I DIAMETER I THICKNESS I MATERIAL
list all appltcahle well coosrrnction pennils 0,a.UIC,County,State,flariance,etc.) ft, fA
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public fa ft. in.
GeQ*errnal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
IndustriaVCommercial Residential Water Supply(shared)
I&GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ti• Port Cement Pour
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salini Bier 19.SAND/GRAVEL PACK if a livable
tyarr FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. fr.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothenmal(Heatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION eolor March soil/rock aim size.etc
Q & -r7 ft. Sad
4.Date Well(s)Completed: _ Well 1D# 7 ft. ft.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3 rE.5 `Fa ME' " ( d ft. ft. a..
Physical Address,City,and Zip Ctrc.V C,w� J,7�`2j3 ft. ft.
Yy .,
=�`r,i- s 379 9 �5-,`t US Zt.REMARKS
County i1 orma i0 r s .
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is syfficient) 22.Certific
74fl S 6, d N q° 'A6 E-741� - W .�.�
f- I� - zi
6.Is(are)the well(s)I Permanent or Temporary si re of Certified Well Contractor Date
Hy signing This form,I hereby cenijy that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or EJNo with!SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out latown well construction information and explain the nature of the coPY of this record has been provided to the well owner.
repair under till remarks section or on the hack gfthis•form.
23.Site diagram or additionaliwell 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:
3:2�d SUBMITTAL INSTRU - IONS
9.Total well depth below land surface:_ _(ft.)
l"b 24a. For All Wells: Submit this form within 30 days of completion of well
r mnlOple wells list all depths ljdi,Qerent(example-3Q200'and 2 a l00')
construction to the following:
10.
f
Division Static water level below top of casing:
Ijwater level is above caving use (ft.) of Water Resources,Information Processing Unit,
" 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
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)-2— Method of test: Air Rotary 24c. For Water Supply&Injection Wells: In addition to sending the form to
HTH �/ the address(es) above, also submit one;copy of this form within 30 days of
136.Disinfection type: Amount: 7dz 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