GW1-2021-05803_Well Construction - GW1_20211025

V1 ELL 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. 70
ft. It.
(A q
NC Well Contractor Certification Number INC15.OUTER CASING(for multi--creased wells)OR LiNER if a licable
CUMMINGS DEVELOPMENTS , C FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 6 5/8 in. .188 G.STEEL
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 9101 W a iN a I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, i/ariance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
_ Industrial/Commercial Residential Water Supply(shared) 18.GROUT
7-1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
,Monitoring 13Recovery
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
I Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) nTr'acer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Coolin Return FROM TO DESCRIPTI N(color,hardness,soiUmck c, rain sbe,etc.)
( g/ g ) J Other(explain under#21 Remarks) ft.
4.Date Well(s)Completed: 0' Z( Well ID# q ft. ft.
fl'
5a.Well Location: n/y�
6 1? (d_�e t JMa°5` /r'�"�QI' ft. ft.
Facility/Own&Aame Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip
ft. ft. racessing UM
21.REMARKS r1'
County ` d— Parcel Identification LN!/o.l((PPiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long4s sufficient) 1 22.Certific ' n'
3S°SS.qqS N '7q° i L-4si W
6.Is(are)the well(s)o Permanent or OTemporary aturc of cll Contractor Date
By mg this jarm, 1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or EJNo uh I5A NCAC 02C.0100 or, 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fell out known well construction information and explain the natur e 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: /20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3!{ (ft.) Division of Water Resources,information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i I.Borehole diameter: 6 (in.) 24b. For Injection 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) Method of test: AIR ROTARY 24c.For Water Supply&Iniectlon 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: XZG't 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