GW1-2021-07366_Well Construction - GW1_20210921

,.�, � Priht Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4448A ft. ft. ! ? 4*1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells) R LINER if a licable
Cummings Developments, Inc C C� (� r� FROM TO DIAMETER THICKNESS MATERIAL
C ft. ft. in.
Company Name
•s�� +t 6 PVC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: W 7-I `�t�� FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Vi?W,Stat, arianre.,etc) fr. ft. in.
3.Well Use(check well use): fr. fr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
IndushiaVCommercial DResidential Water Supply(shared) 1S.GROUT
In7 ation FROM I TO MATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. D �
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge nGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier19.SAND/GRAVEL PACK if alicableer FROM TO MATERIA I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain sim,etc.)
ft. I ft.
4.Date Well(s)Completed:'Z 7 7-1 Well ID# fr. Lr Q ft. go 01
5a.Well Location: ft• ft.
Ar A ul A- Cn. ft. tt.
FacilitMv.4crName Facility lD#(ifapplicabic) ft• ft.
lot{ �1t Nill �L11fIN� '�� �iL�S4,,nrf�u-,708 ft. ft.
Physical Address,City,and Zip ft. ft.
(� tl$4601a.7 , 21.REMARKS'
County 0Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if
well field,one]at/long is sufficient) y 22.Certificatio .
,J4a 04• 13 7'
N 11003 • S /"1 / W
6.Is(are)the well(s)oi Permanent or Temporary of Ccrtifi e I 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: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis 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 a•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: Wa SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
/f water level is above 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 thi's form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 441"1 24c.For Water SuoDlit&Injection 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: � � completion of well construction to the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016