GW1-2021-07381_Well Construction - GW1_20210921

iWELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CH RI STOPH E R WATCHER 14.WATER ZONES
Well Contractor Name FROM ro DESCRIPTION
4448A /tJ 2",Spt)/
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells ORiLINER if a livable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 11DC�/ ft. 6 5/8 in. 188 G.STEEL
Company Name
�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 4-7 a t GJ) W -1Z 1 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 []Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft. ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
_ _Irrigation FROM TO WTERIAL EMPLACEMEW METHOD&AMOUNT
Non-Water Supply Well:
:)Monitoring 13 Recovery
Injection Well:
ft. ft.
Aquifer Recharge r1l Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
-
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) MTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiltrock e, rain sim,etc.)
Of[. -) ft. T.;/
4.Date Well(s)Completed: o"7i Well ID# tt. 240 ft. aA
5a.Well Location:
Facility/ er Name Facility ID#(if applicable) ft. ft.
Lod 4 - 77-2 0 1J NC. (oa Nw a �r„�W ft.
Physical Address,City,and Zip J ft. ft. Slag It
9900 1 -19 I1.REMARKS {1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long ispufficient) 22.Certification*
Gd13. 241 N �q° (R• qff w _ o -L�
6.Is(are)the well(s)oPermanent or 13Temporary Si lure ified Well Contractor Date
signing this farm,1 herebv certify'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n Ves or EJNo b ,with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
-' If this it 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 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: SUBMITTAL INSTRUCTIONS
�9.Total well depth below land surface: 6"�
(� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent("example-3@200'anndd 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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: .0-4®� 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 Watcr Resources Revised 2-22-2016