GW1-2021-07384_Well Construction - GW1_20210921

Prnt�,Form� ';
' 'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A
ft. ft. t H gg
NC Well Contractor Certification Number INC15.OUTER CASING(tor multi-cased',-wells'OR LINER if a licable
CUMMINGS DEVELOPMENTS, C FROM TO DIAMETER THICKNESS MATERIAL
+1 f[. 11 ft• 6 5l8 In' .188 G.STEEL
Company Name !!
�p `(� ]6.INNER CASING:OR TUBING( eothermal iclosed-loo "
2.Well Construction Permit#: �30 t WEUNZI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Parlance,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) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial E)Residenrial Water Supply(shared) IS.GROUT
_- hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
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 ElStortriwater Drainage +f1I
Experimental Technology Subsidence Control tt.
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,soil/rock type,grain size,etc.)
ft. 2-
4.Date Well(s)Completed: (ell ID# ' fL :ZQO tt.
5a.Well Location:
ft. ft.
SQ6"ll55et 51
Facility/Owner Name Facility lD#(if applicable) ft. ft.
to8gs 1pl l a-la l
Physical Address,Cit 4, d Zip p r� ft. ft. Information Processing Unit
�X� 21.REMARKS UWK Section
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
N-7 y 40I q 61aW i 7-2
6.Is(are)the well(s)oPermanent or 13Temporary Signature c d Well Contractor ate
By sig g this form,I hereby 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
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 oil 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
I
construction,only I GW-I 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: 'Z(�700 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(7n 200'and 2Q100') �.. construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/(water level is above casing,use'•+ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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: Zdoz 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