GW1-2021-07365_Well Construction - GW1_20210921

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W kLL CONSTRUCTION RECORD GW V For Internal Use Only:
1.Well Contractor Information: � `
Christopher Watcher 14:WATER ZONES
Well Connector Name FROM TO DESCRIPTION
44 48tt1 p0�'�J�`� ft ft. LP
ter ft. ft.
NC Well Contractor Certification Number W%V') �L
15.OUTER CASING for multi cased wells;OR IaINER.if,'a licable
Cummings Developments, Inc FROM TO DIAMETER THtCKNESS MATERIAL
Company Name
+t fL ft. 8 ia. PVC
' + 16.INNER CASING OR TUBING: eothermal closed.lomil
W 2.Well Construction Permit#: a, — y o$a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ti.e.UIC.County,State,variance,etc) ft ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17:.SCREEN
L_aFROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) csidential Water Supply(single) ft. fr. In.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: ft, ft. � a
Monitoring _•Recovery
Injection Well:
Aquifer Recharge oGroundwater Remediation ft. ft.
RAYE
Aquifer Storage and RecoverySelinity Barrier 19.SANDIG L PACK fif alicableFROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. fr•
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20 DRILLING LOG attach additional sheets If necessary)-
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks} FROM TO DESCRIPTION{color,dardn salUrock rain size,etc.{
� fL ft. a.
4.Date Well(s)Completed: ft.Well ID# it.
5�a.Well Location: ft• ft.
l JG11t�C. `041^54•, ft. fr.
Facility/Owner Name t ) Facility ID#(if applicable) It. ft.
Lo3o4 "AYfY umLo1 CS 'TA ECtar%J W—2 72A ft. ft.
Physical Address,City,and Zip�— ft. ft.
p
0(0_1 G l 37.7 a 4�1 � 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) � 22.Certifi on'
6.Is(are)the well(s) IPermanent or Temporary Z=crtifled WeII Contractor Datc
e form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 thisform. 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: z 10 U (R•) 24a. For All Wells: Submit this forat within 30 days of completion of well
For multiple wells list all depths if different(example-3®20 '''}aud 2Q100') construction to the following:
10.Static water level below top of casing: yi (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: ('- 24c.For Water Suaaiv&Injection Wells: In addition to sending the form to
the address(es) above, also submit i one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016