GW1-2021-07345_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
FROM TO DFSCRIP9'ION
Well Contractor Name 0-5
4448A
0 6 L 3 31 ft-
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if up Iicable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 75 ft. 6 518 in. 188 G.STEEL
Company Name
16.1NNER CASING OR TUBING eothermalidosed-loop)
2.Well Construction Permit#: 4_1 18 W EU a 2 I 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
Agricultural ©j MunicipaUPublic ft. ft. in:
Geothermal(Heating/Cooling Supply) 69Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACkMENT METHOD&AMOUNT
Non-Water Supply Well: Q fa -Z 15 ft. e
Monitoring QRecovery ft. fr.
Injection Well:
ft. fr.
Aquifer Recharge EiGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stonnwater Drainage ft. ft.
j Experimental Technology Subsidence Control ft. ft.
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM: I TO DESCRIPTI '(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) D ft.too
tt.
4.Date Well(s)Completed: ` 21 Well ID# ft. 1X ft.
5a.Well Location:
Facility/Ow Name Facility 1D#(if applicable) ft. ft.
-7-7 30 %,)NC_ t�wutn� �;�� ft.
Physical Address,City,and Zip ft. ft.
Pm 99010!AS toto 9 a 21•REMARKS e rVA410,0r O
County Parcel Identification No.(PIN) ,� 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long istufficient)
/ 22. rti c tion:L2
3(,° 13 ,W N Jq° �q�.3S8 W
6.Is(are)the well(s)oPermanent or Temporary Sigllrurc of Certified Well Contractor Date
By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:
&.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: 0 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: QA (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: /�/T,l 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: 330z. completion of well construction to the county health department of the county
where constructed. r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016