GW1-2021-00737_Well Construction - GW1_20210401

WE&I CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Cummings 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3170A ft. ft' I 2 )S z :zV 1 q 7
ft. ft. 22- V f- -7
NC Well Contractor Certification Number 1.5.OUTER CASING for multi-cased wells OR LINER if a l!cable
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft 6 5/8 in. .188 Galy Steel
Company Name , f '+Q '.W` 16.INNER CASING OR TUBING eothermal closed-loop)
`I
2.Well Construction Permit#: W t e-N Z 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11(,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
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) ffResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO "' Port Cement Pour
Monitoring Recovery ft ft.
Injection Well:
Aquifer Recharge 00roundwater Remediation ft. ft.
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK if a licable
ty FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft-
Geothermal(Closed Loop) OTracer
20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) 00ther ex lain under#21 Remarks FROM TO DESCRIPTION color,hardness,soittrock type.grain size,etc
® ft. -7 ft.
4.Date Well(s)Completed: ', Well ID# 7 fr• 220 tt. OG
5a.Well Location: ft. ft.
"C ft. ft.
C it 1r C �+�cl r
Facility/Owner 1 ame Facility ID#/n(if applicable) ft. ft.
_ 'RS (G �Dn u3occl-D( . C'r, �7 tiR ft. ft.
Physical Address,City,and Zip ft. ft AVR X
SG 11.REMARKS
County Parcel Identification�3No.(PIN) ^il�•D C�j7C0.
i
'v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
laagfficient) Y 22.Certification:
-35056tsh N -710 a6r 6 P W
6.Is(are)the well(s)E Permanent or OTemporm Si re fi ell Contractor Date
y signing this form,I hereby certify that the well(.v)was(were) -onvlrucl, in accordance
7.Is this a repair to an existing well: ®Yes or InNo with iSA NCAC 01C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well constrecYion information and explain the nature of the copy of fills record has been provided to the well owner.
repair under h2l remarks section or on the hack of this farm.
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 1 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 depot below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
multiple wells list all depths if di/jerent(ex
For nra ample-3Q200'a2nd 2@100� construction t0 the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
ff 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
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) Method of test: Air Rotary 24c.For Water Supply& Injection 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: Z 21!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