GW1-2021-04193_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
'1.Well Contractor Information: s
Christopher Cummings 14.WATER ZONES
Well Contractor Name FROM
ft TO DESCRIPTION
`y3170A
ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING(for maltircased,wells OR_LINE&if a"]icatile `_:
Cummings Developments, Inc. FROM TO DIAMETER THICKNESS MATERIAL
r, . +1 ft. ft. 6 5/8 in. � 6ei�l v
Company Name
-F 16.;INNER CASING OR TUBING(geothermal closed-loo
2:Well'Construchon'Permit#: W Z6 - OL71 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'- SLOT SIZE THICKNESS MATERIAL
Agrioultuial ` Ft OMunicipal/Public ft. ft. ice'
Geothermal(Heating/Cooling Supply) IZResidential Water Supply(single) ft. ft. in.'
Industrial/Commercial Residential Water Supply(shared)
18:&ROUT'.
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 20 & Port Cement Pour
__ Monitoring _ Recovery {L {t,
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19:SAND/GRAVEGPACK-fifaimlicablO
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft. I
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additimW sheets'if necessa
FROM TO DESCRIPTION color,hardnes soil/rock type.grain sim etc
Geothermal(Heating/Cooling Return) Other(explain under.#21 Remarks)
ft. ft. p l
4.Date Well(s)Completed: Well ID# ft. Z ft Oe.3�,
55aa.Well Location: it. ft.
17�1G�C 16AY-$ rt. ft.
F—ac7ili7/OverIjgter, n�• � �.Facility ID#�ifapplicable) ft. ft. E ,E u
ft. ft.
Physical Address,dty,and Zip ft. ft.
Cilraln,tr 019 L 45l0 34 9 3 zI:REMARKS' .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlo}ng its sufficient) ec 5 22.Certifieatio
N 7�c ��l • UJIo W I-ZZ -Z l
6.Is(are)the well(s)oPermanent or ElTemporary Si�eofCd Well Contractor Date
,I herehy'certify that the well(s)was(were)constructed in accordance
7.Is this a repair to nn existing well: Oyes or )No trh/5A NCAC 02C.0100 or l5A NCAC102C.0200 Wel!Cons[ruclion Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofihis record has been provided to the well owner.
repair under 112l remarks section or on the hack 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also at additional pages if necessary.
drilled:_.- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /2,Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor 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: 1d51 (ft.) Division of Water Resour I Information Processing Unit,
Ijwater lovel is shove 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
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&Iniectionl Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of l
13b.Disinfection type: HTH Amount: 2 O 7- 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