GW1-2021-07388_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESC TION
ft.4448A fr. 2,0
ff. rt. ''�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR INNER if a licable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft. ft. 1 6 5/8 in. .188 STEEL
o 16.INNER CASING OR TUBING `eothermal closed-loop)
2.Well Construction Permit#: �'O 32 W F L N Z' 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. ff. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) RRResidential Water Supply(single) ft. ft, in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
_) Irri ation FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
fr. Zo ft.
J Monitoring Recovery
Injection Well:
ft. fr.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return FROM To DESCRI TION color,hardness,soil/rock e, rain size,etc.)
( g/ g ) J Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:-7' '2 1 Well ID# ft. ft. r( C
y5aa.Well Location:
l� t r\QY`A IrI.I�1'�+Ir ft. ft.
Facility/Owner Name Facility ID#(if applicable)
M' 141 3oZ fr. rt.
Physical Address,City,and Zip ft. ft. l
t�- Cl gab a 4013 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F�wR
(if well field,one latAong is sufficient) 22.Certificati
35° $-7 -fML N Via°i r. a$y W 10 rS-2
6.Is(are)the well(s)EDPermanent or rITemporary Si turc o ed Well Contractor Date
B gning this form,I herebv certify-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes 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 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 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exanhple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: I (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
13a.Yield(gpm) 40 Method of test:141.1-JUIZ 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: A"V t 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