GW1-2021-07379_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 I
Well Contractor Name FROM TO DESCRIPTION
4448A ft. I
ft. e'f /17
ft. ". I-)
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells OR;LINER if a licable
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft' A ft' 6 5/8 in. .188 G.STEEL
(/
''`rG �`LTV 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: q t) 7-11 FROM TO DIAMETER THICKNESS MATERIAL
W
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 SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. I in.
Ji Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
m Industrial/Comercial Residential Water Supply(shared) 18.GROUT
71
Irrigation FROM �^1TOO_ MATERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: ft' o�iJ fL aeh U
:)Monitoring ©Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19 SAND/GRAVEL'PACK if a licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storrnwater Drainage
_1 Experimental Technology Subsidence Control f[. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft.
4.Date Well(s)Completed: l Z Well ID# dcft. ft. e e/
5a.Well Locatio ft. ft. •
JG& .r ft.
Facility/O ame L o4% Facility ID#(if applicable) ft. ft.
soi o p cu\ k ! d 'v-'NvLA 2vas ft. ft. g��«
Physical Address,City,and Zip 4.J ft. ft.
Q N ie TO
at C O(1 21.REMARKS P
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
3G°l3 . 6�2 N 716lq-9,7y W
6.Is(are)the well(s)0 Permanent or OTemporary Si of Clf r ed 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: JDYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 oJ7his 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 I 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: �Q� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'andd22@l00') construction to the following:
10.Static water level below top of casing: J (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 addiltion 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 Ceenter,Raleigh,NC 27699-1636
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:_�_%� 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