GW1-2021-07389_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
Well Contractor Name FROM TO DESCRIPTION
4448A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER'ifa licable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 2 3 1- 6 518 in. .188 G.STEEL
Company Name
{,�q / -, 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: met;Q W E L IM ZI 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.
17.SCREEN
Water Supply Well: '
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 RResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO TERIAL EMPLACE 4ENT METHOD&AMOUNT
Non-Water Supply Well: v ft. 2,0
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stomlwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) nTraeer 20.DRILLING LOG'(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks)
rt. �•a j
4.Date Well(s)Completed: 2� Wel1ID# �� tt. Z ® ft.
5a.Well Location:
` tLSA n S•I`'`- --
Facility/O Name/ Facility ID#(if applicable) ft. ft.
I In (mil IC i AA"K Ck s` v��t
Physical Address,City,and Zip Qq MM Q ft. ft. OGeS
_I_]w01` IOI 21.REMARKS
County Parcel Identification No.(PIN) 013 ` Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llat/long is sufficient) �f Q 22.Certification•
J l y)?r 4 1lo L�, N / / r I 1�}•DA 1 / W �✓ I�Zi�
6.Is(are)the well(s)oPermanent or 13Temporary Signa a of C 'red Well Contractor Date
mg this form,!hereby cerJ that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJYes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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-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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f 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) 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: 22,12— completion of well construction tof 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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