GW1-2021-07380_Well Construction - GW1_20210921

Print Form �Y
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
A.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
4448A e. q2 ft.
rt. ..� ft.
j
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased.wells):OR LINER'if a lieable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft. ft' 6 518 in. .188 G.STEEL
1 ]6.INNER CASING OR'TUBING eothermal:closed-loo
2.Well Construction Permit#: 41 19 W EL N 2 l 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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft• ft• in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ _Irrigation - FROM TO MATERIAL EMPLAC NT METHOD&AMOUNT
Non-Water Supply Well:
_I Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL":PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storuiwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additiotial,sheets'if necessary
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,grain Sim,etc.)
. 75 ft. e
4.Date Well(s)Completed: — 1 �1 10 ft-
ID# ? ft. Olt) ft.
5a.Well Location: ft. ft.
broe s5
Facility/Own ame Facility ID#(if applicable) ft. ft 1
€.. P 6w
-7 / 5`0 `V N C. ttW� Loa Ur t[lCf[In ft ft
Physical Address,City,and Zip ft. ft. (OGe$
o 9 21.REMARKS P.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong isluffrcient) Q a 22 if ation:
7 013r11P N -710 —1•�� / ' W
6.Is(are)the well(s) Permanent or OTemporary S urc of Certified Well Contractor Date
By signing this form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo 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 o0he copy of this 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:
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 constivction details. You may also attach additional pages if necessary.
drilled: (� SUBMITTAL INSTRUCTIONS t '
9.Total well depth below land surface: !O (fury 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'Iand 2Q100') construction to the following:
10.Static water level below top of casing: // (ft.) Division of Water Resources,Information Processing Unit,
ll"water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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I I.Borehole diameter: 6 (in.) 24b.For Infection 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
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13a.Yield(gpm) Method of test: Y 24c.For Water Supply&Iniecti6n 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: ZSQ�. 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
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