GW1-2021-07378_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher �.� �` 14'WATER ZONES, -:.
Well Contractor Name vo FROM TO DESCRIP'r1ON
4448A t ©2 '(-9 ft. 1 ft.
IL
NC Well Contractor Certification Number ;;OI3TER:CASING formals-case
ft. ft.
d wells�OR.LINER:SM'a 'livable
Cummings Developments, Inc `�,rPi`5� FROM TO DIAMETER THICKNESS MATERIAL
Company Name
c7 +t ft. ft. 6 in. PVC
�C \M``�+ C L� ✓t�� �L t
,16,INNER'CASING'OR TUBING(`eothermal
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County.State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: M SCREEN. _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft, in:
Geothermal(HeatinglCooling Supply) QResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) yg,GROUT '_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7Et �,
Monitoring __)Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK if ai fixable::,
Aquifer Storage and Recovery 0Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stoimwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20:'DRILLING,LOG!attach idditibtial!sheets•if nediisar')E
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnem soiltroek type rain sire,d0
ft. ft. S
4.Date Well(s)Completed: -31'Z( Well ID# fr. t �� it- r
Sa.Well Location:
ft. ft.
ft. ft.
►C�QQ..\ t"CMw�t)d�"�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
3p7�Snn&A C_1nxt_'7 r_ 1.rwb�r'ltal. o 05K
Physical Address,City,irsaip ft. ft.
�f�JfSi3C1 1��J�of o tP 21-.REMARKS --
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslminutestseconds or decimal degrees:
(if well field,one lattlong is sufficient) / 22.Certifieatio .f
36° i19-OZSl N °5S -S�8 W
6.Is(are)the well(s)opermanent or OTemporary Sipatur ofC ' Cont&ctor Date
By s ng this fora:,1 hereAv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 this fora:.
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some 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 attach additional pages if necessary.
drilled: 0- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �G v (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent("example-3@200'aannd 201001 construction to the following:
10.Static water level ibelow top of casing: G1 (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: 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
t
13a.Yield(gpm) Method of test: 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: 3(ro2 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