GW1-2021-05907_Well Construction - GW1_20211025

I
S Pr:infForm f
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft. , i
ft. ft. 0A '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER if a licable
Cummings Developments, Inc FROM O DIAMETER THICKNESS MATERIAL
+1 ft. ft. 1 6 in. PVC
Company Name
I�` 16.INNER CASING OR TUBING(geothermal closed400
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 TO DIAMETER SLOTSIZE THICKNESS MATERIAL
I Agricultural [3Municipal/Public tt. fr. in.
_1 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fr. in.
1 Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
_,Irri ation FROM TO TERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
Injection Well:
ft. ft.
t-IlAquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery EJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Traeer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP'ION lcolor,hardness,soil/rock e, rain sizx,etc.)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) O ft. $ ft. ' 1)
4.Date Well(s)Completed:B�zS Z J well ID# ft. 2-W ft.
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1
�7
02710 rlo c.r �, r
Physical Address,City,and Zip ft. fr. Inn
pIQCe
n0.�LA` �� ,Z 1 21.REMARKS
`County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
/field,one lat/long is sufficient)� p� 22.Certificatio JG N �qd `A •�� W
6.Is(are)the well(s)fnPermanent or Temporary Signal of ell C!ontractdC Date J l
By mg this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 1 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: -.zoo (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(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,
ffwater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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 3LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection 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: �X102 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
_tip